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Plate I 



I'CCO-S-HARHIS » sons, PHI LA. 


Neevns Lipoma lode s . 

(From a Photo £>raph of one of tlie author's patients.) 

( Frontispiece.) 




A PRACTICAL TREATISE 

ON 

DISEASES OF THE SKIN 

FOR THE USE OF STUDENTS AND PRACTITIONERS 


FOURTH AND REVISED EDITION 



JAMES KEVINS HYDE, A.M., M.D. 


JJ 

PROFh R OK SKIN NO VEN 5RF4I. DISEASES, BUSH MEDICAL COLLEGE, CHICAGO ; DERMATOLOGIST TO THE 
PK. Y I EH [A N, AUGUS’A A, AND MICHAEL REESE HOSPITALS OF CHICAGO ; AND CONSULTING 
DERMATOLOGIt. TO THE CHICAGO HOSPITAL FOR WOMEN AND CHILDREN; 


AND 


FR ANK ^MONTGOMERY, M.D., 

LECTURER ON DERMATOLOGY AND GENITOURINARY DISEASES, AND CHIEJ ASSISTANT TO THE CLINIC 
FOR SKIN AND VENEREAL DISEASES, RUSH MEDICAL COLLEGE, CHICAGO ; ATTENDING PHYSICIAN 
FOR SKIN AND VENEREAL DISEASES, ST. ELIZABETH HOSPITAL, CHICAGO 


ILLUSTRATED WITH ONE HUNDRED AND TEN ENGRAVINGS AND 
TWELVE PLATES IN COLORS AND MONOCHROME 



T 

i J 


A BROTHERS & CO. 




PHILADELPHIA AND NEW YORK 


1897 




\'" 




Entered according to the Act of Congress, in the year 1897, by 
LEA BROTHERS & CO., 

In the Office of the Librarian of Coagress. All rights reserved. 


DORNAN, PRINTER. 





\ 


52 

aJ 

-4 




TO 


MORIZ KAPOSI, 

PROFESSOR OF DERMATOLOGY IN THE UNIVERSITY OF VIENNA, 


AUSTRIA. 


WITH HIS CONSENT 








PREFACE TO FOURTH EDITION. 


The sudden demand for a fourth edition of this work has restricted 
the labor of revision to a few months; but within this limited period 
of time it has been possible to alter, and, it is believed, also to im¬ 
prove, almost every page. New chapters have been added, or the 
old rewritten, on Hydrocystoma, Seborrhea, The Simple Erythe¬ 
mas (including Erythema Scarlatiniforme), Erysipeloid, Conglom- 
erative Pustular Perifolliculitis, Eczema Folliculorum, Dermatitis 
Seborrho'ica, Dermatitis Repens, Hydroa Vacciniforme, Epidermo¬ 
lysis Bullosa Hereditaria, Hydradenitis Suppurativa, Keratosis Fol- 
licularis, Morvan’s Disease, Frambesia, Ulerythema Ophryogenes, 
Colloid Metamorphosis of the Skin, Adenoma, Multiple Benign 
Cystic Epithelioma, Myoma, Angioma Serpiginosum, Lymphan¬ 
gioma, Mycetoma, Angiokeratoma, and Protozoan Disease. Crit¬ 
ical corrections also have been made, or new paragraphs added, in 
the chapters devoted to General Therapeutics, Lichen Planus, Der¬ 
matitis Herpetiformis, Eczema, Verruca, Molluscum Epitheliale, 
Fibroma, Xanthoma, Elephantiasis, Angioma Pigmentosum et Atro- 
phicum, Tuberculosis, Erythema Induratum, Leprosy, Carcinoma, 
Acne, Lupus Erythematosus, and Trichophytosis. 

The doctrines based upon the recent progress of dermatological 
science which have not been completely established have been for 
the most part briefly noted, while essential facts, those especially 
resting upon pathological and bacteriological research, have been set 
forth and, when practicable, considered in detail. By the omission of 
material that no longer possesses value it has been found possible to 
make required additions without increasing the size of the book. 

Three new plates and five new engravings have been introduced as 
additional illustrations. 


VI 


PREFACE TO FOURTH EDITION. 


The author is pleased in this edition to place the name of his asso¬ 
ciate upon the title-page as an evidence of valuable assistance in the 
preparation of this fourth edition. 

The thanks of the author are tendered to Dr. W. F. Robinson for 
effective aid while the work has been passing through the press. 


Chicago, January, 1897. 


J. N. H. 


PREFACE TO THIRD EDITION. 


The labor of preparing for the press a third edition of this treatise 
has been expended with a view to the correction and improvement 
of every page. The greatly increased attention to the subject of 
Dermatology, influenced largely by the transactions of scientific bodies 
both in America and Europe whose work has been limited to the 
field of cutaneous medicine, and the numerous important publications 
devoted to the same theme in most of the modern languages of the 
civilized world, have rendered it difficult to secure for a text-book of 
this scope comprehensiveness and conciseness in an equal degree. 

Thirty-five new diseases are with greater or less fulness considered 
in the present edition. The chapter on Tuberculosis has been wholly 
rewritten and considerably enlarged, with a view to furnishing an 
exposition of this important subject from the point of view of modern 
bacteriology and histology. Lupus Vulgaris has been in that chapter 
properly relegated to a position among the verrucous and other cuta¬ 
neous manifestations of tubercle-infection. Among other new and 
important chapters added may be named that on Pityriasis Rubra 
Pilaris, on Keratosis Follicularis, with several minor disorders tem¬ 
porarily considered in the same category, on Actinomycosis, on Leu- 
cokeratosis Buccalis, on Xanthoma Diabeticorum, and on Pemphigus 
Vegetans. Among the several chapters of minor importance also 
added may be named those on SavilPs Disease, on Scarlatiniform 
Erythema, on Acanthosis Nigricans, on Angioneurotic (Edema, on 
Acromegalia, on Alopecia Follicularis, on the Parasitic Forms of 
Eczema, on several varieties of Gangrene of the Skin, on some of 
the rarer diseases of the tropics, and on a few of those involving the 
hair and nails, both simple and parasitic. 

It has been found necessary, with a view to the needs of the prac¬ 
titioner and student, still to adhere in part to the classification of the 



PREFACE TO THIRD EDITION. 


viii 

American Dermatological Association. This has served as the ground¬ 
work for a variation demanded by the later advances in dermatology. 
For convenience, the coccogenous and bacillogenous dermatoses of 
inflammatory type have been here grouped together under a common 
heading. 

The new and original illustrations designed especially for this 
edition consist of five plates and twenty-two woodcuts. Of the 
latter, five represent careful drawings of sections of the skin, made 
under the author’s special supervision. The colored and other draw¬ 
ings of cutaneous disease are reproduced either from paintings in oil 
or from photographs of clinical patients. 

The author has to express his special indebtedness to the valuable 
second edition of the work of his friend, Dr. H. Radcliife Crocker, 
of London, which has appeared since these pages have been passing 
through the press; also to the second edition of the practical and 
compendious treatise of Brocq, and to the current International Atlas 
of Rare Skin Diseases, which has become the important exchange for 
the dermatological experts of all nations. 

He is also greatly indebted for aid in proof-reading and indexing 
to his associate, Dr Frank H. Montgomery, and to his assistant, Dr. 
W. F. Robinson. 


Chicago, September 1,1893. 


PREFACE TO FIRST EDITION. 


The increasing recognition of the gravity of many cutaneous dis¬ 
orders and of the importance of their accurate study is shown by 
the rapidly augmenting number of observers in this department of 
medicine and by the numerous valuable contributions constantly 
made to it, both in this country and abroad. For the convenience 
of the general practitioner it therefore becomes necessary at shortly 
recurring intervals that some one should attempt the task of pre¬ 
senting in a comprehensive form the results of the latest observation 
and experience. 

The author is aware of the degree to which he must claim indul¬ 
gence in the present effort to perform this duty. The extent of the 
subject and the limitations of a single volume require the omission 
of much detail of secondary importance. With regard to that which 
it has seemed proper to include, he has endeavored to write concisely, 
to set forth only what can be held as the truth, to be frank in the 
admission of the weakness with which the most skilful physician 
stands in the presence of many grave and not a few benign dis¬ 
orders, and to cultivate a wholesome doubt of that which has not been 
shown to be worthy of trust. How far he may have fallen short of 
attaining this end these pages will declare. 

He has to express his indebtedness to the staudard works on der¬ 
matology of foreign authorship, especially to the exhaustive and 
invaluable work of Hebra, and to the Lectures on the Diseases of 
the Skin lately given to the profession by Professor Kaposi, which 
contain the mature conclusions of his vast experience. With these 
should be named the writings of Sir Erasmus Wilson, Dr. Tilbury 
Fox, Dr. Neumann, Dr. McCall Anderson, Dr. Behrend, and the 
syphilographers, to whose works special reference is made in the 
chapter devoted to their theme. Among the books of American 
authorship, he is under special obligation to the sterling work of Dr. 
Duhring, of Philadelphia, and to the excellent treatises of Drs. Pif- 
fard, Fox, and Bulkley, of New York. 

All these are named by title in the brief and selected bibliography 
appended at the close of the volume. No less valuable aid has been 


X 


PREFACE TO FIRST EDITION. 


obtained by consulting the papers of American and foreign authors 
contained in the journals especially devoted to diseases of the skin, 
amoug which, as the representatives of the English tongue, the 
Archives of Dermatology, lately edited by Dr. Bulkley, and the 
current Journal of Cutaneous and Venereal Diseases, edited by Dis. 
Piffard and Morrow, deserve special mention. 

The author is also very greatly indebted to Dr. Charles Heitzmann, 
of New York, not merely for the information gathered from the study 
of his original researches in pathology, but particularly for his kind¬ 
ness in furnishing advance sheets of the chapter on the skin, in his 
work on Microscopic Morphology, which has just issued from the 
press. From this work, with Dr. Heitzmann’s permission, several 
illustrations have been borrowed, which appear in the chapter on 
anatomy, the details of which subject are also very largely drawn 
from the same rich store. The first of the drawings representing 
sections of the skin is from the faithful pencil of Dr. H. D. Schmidt, 
of New Orleans, who, in order to produce it, interrupted, without 
hesitation, his arduous labors in connection with the subject of path¬ 
ology. To his colleague, also, Dr. Frederick W. Mercer, of Chicago, 
the author is glad to express his indebtedness for the skill with which 
a number of pathological specimeus have been prepared and mounted 
for special study, and original drawings produced for the first and 
subsequent chapters of the book. To Dr. Duhring, of Philadelphia, 
he is further indebted for valuable suggestions made during the course 
of preparation of the manuscript. 

Medicinal measures are, in these pages, expressed in terms of both 
the apothecaries’ scale and the metric system. It is to be noted, how¬ 
ever, that the latter are not in all cases literal translations of the 
terms of the former, many of the formulae, especially those for 
preparations designed to be topically employed, being metrically 
composed, the relative proportions of the ingredients remaining 
unchanged. 

The changes which it has been advisable to make in the matter of 
nomenclature, classification, and other equally important subjects are 
concisely explained in the chapters devoted to each. 


Chicago, February, 1883. 


CONTENTS. 


PAGE 

Anatomy and physiology of the skin . .17 

General symptomatology.50 

General etiology.61 

General diagnosis ... .67 

General prognosis.72 

General therapeutics.73 

Classification.. 93 


DISEASES OF THE 

SKIN. 


CLASS I. 

DISORDERS OF THE GLANDS. 


Of the Sweat-glands . 


. 97 

Hyperidrosis....... 


. 97 

Sudamen. 


. 100 

Miliary fever ...... 


. 102 

Hydrocystoma. 


. 103 

Anidrosis. 


. 104 

Bromidrosis. 


. 105 

Chromidrosis. 


. 106 

Greenish sweating .... 


. 106 

Uridrosis .. 


. 108 

Haematidrosis. 


. 108 

Of the Sebaceous Glands 


. 109 

Seborrhea .. 


. 109 

Asteatosis. 


. 121 

Comedo ....... 


. 122 

Milium. 


. 127 

Steatoma. 


. 129 

Congenital fibro-sebaceous disease 


. 131 

Multiple dermoid cysts 


. 131 

Rare consequences of sebaceous disease 


. 131 

























CONTENTS. 


xi 1 


CLASS IT. 

INFLAMMATIONS. 


Exanthemata 

Morbilli .... 
Rotheln .... 
Scarlatina .... 
Variola .... 
Varioloid .... 
Varicella .... 
Vaccinia .... 
Erythema .... 
Erythema intertrigo 
Erythema scarlatiniforme 
Erythema multiforme 
Urticaria .... 


Urticaria pigmentosa 
Angio-neurotic oedema 
Dermatitis . 

(A) Traumatica . 

(B) Venenata 

(C) Calorica 

Congelatio 

(D) Medicamentosa 

Feigned eruptions 
Chronic pustular dermatitis wit 
patches .... 

(E) Gangrenosa. 

Spontaneous gangrene of skin 
Gangrenosa infantum 
Multiple gangrene in adults 
Spontaneous gangrene of the eyelids 
Symmetrical gangrene of the extremitie 


extensio 


(Raynauc 


)eri 


leral 


’s disease) 


Erysipelas. 

Erysipeloid ...... 

Pellagra. 

Acrodynia. 

Coccogenous and bacillogenous dermatoses 

(A) Furunculus .... 

(B) Anthrax .... 

(1) Anthrax simplex 

(2) Anthrax maligna 

(C) Equinia. 


Pustules from cadaveric infection 
Pustules and other lesions resulting from wounds 
reptiles and insects 

(D) Delhi boil. 

Phagedena tropica . 

(E) Phlegmona diffusa 


nflicted by 


PAGE 

132 

132 

136 

137 
142 
144 

150 

151 
155 
158 
162 
163 
169 

171 

172 

179 

180 
180 
183 

185 

186 

196 

197 
197 

197 

198 
198 

198 

199 
199 

205 

206 

207 

208 
208 
212 
212 
215 
217 
219 

219 

220 
221 
222 

















CONTENTS. 


xm 


iculitis 


(F) Sycosis. 

Scar-leaving sycosiform dermatosis 

(G) Impetigo 

(H) Impetigo contagiosa 

(I) Ecthyma 

(J) Conglomerate pustular perifo 
Herpes. 

Herpes facialis 

Herpes progenitalis 

Herpes iris . 

Herpes gestationis 
Herpes zoster 

Dermatitis herpetiformis . 

Pompholyx 

Psoriasis .... 

Pityriasis maculata et circinata 
Dermatitis exfoliativa 

Dermatitis exfoliativa infantum 
Pityriasis rubra. ... 

Pityriasis rubra pilaris 

Epidemic exfoliative dermatitis 

Parakeratosis variegata 
Lichen ruber 

Lichen ruber moniliformis 
Lichen planus 

Lichenification 
Eczema .... 

Local varieties of eczema 
of the scalp . 
of the face 
of the lips 
of the nostrils 
of the ears 
of the eyelids 
of the genital organs 
of the anus and the anal region 
of the nipple and breast of wome 
of the extremities . 
of the hands and feet 
as it affects the nails 
of the tropics . 

Universal eczema 
Parasitic varieties of eczema 
Dermatitis seborrhoica—eczema seborrho'icum 
Dermatitis repens . 

Prurigo 
Acne 

Acne rosacea 
Acne varioliformis 


PAGE 

223 

225 

230 

232 

234 

237 

238 

238 

239 

241 

242 
242 
249 
252 
254 

272 

273 

275 

276 
279 

284 
283 
283 

285 
287 
290 
293 

338 
333 
335 
337 

339 

340 

341 
344 
347 
349 
351 
353 

356 

357 

358 

359 
359 

365 

366 
369 
382 
387 



















XIV 


CONTENTS. 


Impetigo herpetiformis 

Pemphigus. 

Acute. 

Chronic (vulgaris) .... 

Pruriginosus. 

Foliaceus. 

Neonatorum. 

Of young girls (pemphigus virginum) 

Vegetans. 

Hydroa. 

Hydroa vacciniforme, seu estivale 
Epidermolysis bullosa hereditaria 
Hidradenitis suppurativa 


PAGE 

388 

390 

391 

391 

392 

393 

394 

395 
395 

400 

401 

402 

403 


CLASS III. 

HEMORRHAGES. 


Cutaneous hemorrhages .......... 404 

Purpura ............. 405 

(A) Purpura simplex. 405 

Purpura urticans.406 

(B) Purpura rheumatica (peliosis rheumatica) ..... 406 

(C) Purpura hemorrhagica ......... 407 

(D) Purpura scorbutica (scurvy).407 

(F) Purpura pulicosa.408 


CLASS IV. 

HYPERTROPHIES. 


J. Hypertrophies of Pigment .411 

Lentigo.. . .411 

Chloasma.412 

Chloasma uterinum ......... 413 

Melanoderma (chloasma) cachecticorum.413 

Addison’s disease. 414 

Argyria. . 

Anomalous discoloration of the skin. 415 

Chloasma from arsenic ....... 415 

Tattooing . ' 4^5 

2. Hypertrophies of Epidermal and Papillary Layers . . 418 

Keratosis. 4 -^ 

(A) Pilaris. 44 $ 

(B) Senilis. 421 

(C) Follicularis. 422 

(D) Palmaris et plantaris. 424 






















CONTENTS . 


xv 


PAGE 


(E) Angiokeratoma.426 

(F) Follicularis contagiosa.427 

(G-) Hyperkeratosis striata et follicularis.427 

(H) Parakeratosis scutularis ....... 428 

Molluscum epitheliale .......... 428 

Callositas. 432 

Callositas of the hands with unusual complications .... 433 

Perforating ulcer of the foot.433 

Clavus.435 

Cornu cutaneum ........... 436 

Verruca.438 

Multiple cutaneous tumors accompanied with intense pruritus . . 443 

Synovial lesions of the skin ........ 444 

Papilloma. .444 

Nevus pigmentosus ........... 445 

Acanthosis nigricans ..447 

Xerosis ............. 447 

Ichthyosis.449 

Simplex ..449 

Hystrix.449 

Congenita (harlequin fetus) ........ 451 


Linguae...... 

Onychauxis. 

Onychomycosis .... 
Syphilitic onychia 

Congenital dystrophy of nails and hai 
Hypertrichosis . ..... 

Neurotica ..... 
Plica polonica .... 
Neuropathic plica 

3. Hypertrophies of Connective Tissue 
(Edema neonatorum .... 
Acute circumscribed oedema of the skin 
Circumscribed and persistent oedema 
Sclerema neonatorum .... 

Scleroderma. 

Diffuse symmetrical 
Circumscribed (morphea) 


. 452 

. 455 
. 456 
. 456 
. 456 
. 458 
. 460 
. 460 
. 460 

. 464 

. 464 

. 465 
. 466 
. 467 
. 468 
. 468 
. 469 


Morvan’s disease.... 
Elephantiasis .... 

Lymph-scrotum . : : 

Acromegaly .... 
Rosacea. 

(A) Erythematosa 

(B) Hypertrophica 
Frambesia . 

Parangi .... 

Donda ndugu 

Verruga peruana (Peruvian wart) 


475 

476 
479 
479 

482 

483 
483 
485 
487 

487 

488 















XVI 


CONTEXTS. 


CLASS V. 

ATROPHIES. 


4. 


Of Pigment . 

(A) Leucoderma . 

(B) Albinismus . 

(C) Vitiligo 

(D) Canities 
Of Hair 

Alopecia 

Congenital . 

Senile . 

Premature 
Alopecia furfuracea 
Alopecia areata . 

Alopecia follicularis 
Keloid-acne 

Ulerythema aphryogenes 
Atrophia pilorum propria 
Fragilitas crinium 
Trichorrexis nodosa 
Monilethrix . 

Nodose swellings of shafts of hair 
Concretions upon the hair-shafts 
Lepothrix 
Piedra . 

Beigel’s disease 
Tinea nodosa 
Of Nail 
Atrophia unguis . 

Achromia unguis 
Of Cutis 
Atrophia cutis 
Atrophia senilis . 

Partial idiopathic atrophy 
Atrophia maculosa et striata 
Diffuse idiopathic atrophy 
Glossy skin . 

Branching atrophy of the skin 
Multiple benign tumor-like new-growths 
Kraurosis vulvse . 


CLASS VI. 

NEW-GROWTHS. 

1. Of Connective Tissue .... 
Keloid ... 

Cicatricial keloid .... 
Cicatrix 


PAGE 

488 

489 

489 

490 
493 
496 
496 

496 

497 
497 

500 

501 
508 

511 

512 

512 

513 

514 

515 

515 

516 
516 

516 

517 
517 
517 

517 

518 
518 

518 

519 
519 
526 
521 

521 

522 

522 

523 


. 524 

. 524 

. 526 

. 527 














CONTENTS. 


XVII 


Fibroma . 

Dermatolysis 
Neuroma 
Xanthoma . 

Xanthoma diabeticorum 
Colloid metamorphosis of the skin 
Adenoma 

of the sebaceous glands 
of the coil-glands 
Multiple benign cystic epithelioma 
Lymphangioma tuberosum multiplex 
Leucokeratosis buccalis 

2. Of Muscular Tissue 

Myoma 

3. Of Vessels . 

Angioma 

Nevus vasculosus 
Telangiectasis 
Angioma cavernosum 
Angioma serpiginosum 
Lymphangioma . 

Lymphangioma circumscriptum 
Angioma pigmentosum et atrophicum 
E-hinoscleroma 
Tuberculosis cutis 

1. Lupus vulgaris 

of the face 
of the ears 
of the trunk . 
of the genital region 
of the extremities . 
of the mucous membranes 
demisclereux de la langue 
esthiorribne 

2. Tuberculosis verrucosa cutis . 

(A) Verruca necrogenica 

(B) Tuberculosis verrucosa cutis 

(C) Other cutaneous tuberculoses 

Tuberculosis papillomatosa cutis 
Fibromatosis tuberculosa cutis 
Elephantiasis tuberculosa cutis 
Tuberculosis fungosa cutis 
Tuberculosis cutis serpiginosa ulcerativa 
Lymphangitis tuberculosa cutanea 

3. Tuberculosis cutis orificialis . 

4. Scrofuloderma . . . 

Tuberculous dactylitis . . 

Suppurative tubercular lymphangiectasis 
The dermatoses of scrofulous subjects 
Lichen scrofulosorum 


PAGE 

530 

532 

534 

536 

541 

542 

543 
543 
545 

545 

546 

547 
549 

549 

550 
550 

550 

551 
553 

556 

557 

558 
560 
562 

564 

565 

567 

568 
568 
568 

568 

569 

569 

570 
570 

570 

571 

572 
572 
572 
572 
572 
572 

572 

573 

574 

575 

575 

576 
576 















CONTENTS. 


xviii 


Acne group of tuberculoses 
Tuberculous eczema 
Erythema induratum 
Lupus erythematosus . 

Ainhum 
Syphiloderma 
Chancre 

Syphilodermata (syphilides) 

Syphiloderma maculosum 

1. Hyperemic . 

2. Pigmentary 
Papulosum . 

Small acuminate 
Large acuminate 
Small flat 
Large flat 
Yesiculosum . 

Pustulosum . 

Small acuminate 
Large acuminate 
Small flat 
Large flat 
Bullosum 
Tuberculosum 
Tuberculosum serpiginosum 
Gummatosum 

Erythanthema syphiliticum 
Syphilis of the mucous surfaces 
mucous patches 
scaly patches 
Syphiloderma infantile, acquisitum et hereditarium 
Chancroid 
Lepra 

Tuber osa 
Maculosa 
Anesthetica 
Carcinoma . 

Epithelioma 
Tubercular 
Papillary 

Cancer of the head 
of the lower lip 
of the genital organs 
of the extremities . 
of the mucous surfaces 
Paget’s disease of the nipple and areola 
Cancer of connective tissue 
en cuirasse 
Tuberose carcinoma 
Melanotic, or pigmented, carcinoma 


PAGE 

577 

578 
578 
590 

598 

599 
601 
604 
608 
608 
611 
611 
612 
618 

613 

614 

617 

618 
619 

619 

620 
620 
621 
621 
622 
623 

625 

626 
626 
627 
629 
651 

656 

657 

659 

660 

669 

670 

671 

672 

674 

675 
675 

675 

676 
676 
684 
684 
686 
686 













CONTENTS. 


xix 


PAGE 

Sarcoma . g87 

Melanotic whitlow.688 

Primary non-melanotic sarcoma.688 

Generalized primary non-melanotic sarcoma.689 

Recurrent fibroid of skin.690 

Mycosis fungoides.692 

CLASS VII. 

NEUROSES. 

Hyperesthesia.696 

(A) Pruritus.696 

Pruritus narium.697 

Genitalium.698 

Ani.698 

Palmae et plantse.. . . 698 

Prairie itch.704 

(B) Dermatalgia.705 

Anesthesia.706 

Vaso-motor and trophic neuroses.707 

Myxedema.709 

CLASS VIII. 

PARASITIC AFFECTIONS. 

1. Disorders due to Vegetable Parasites.712 

Tinea favosa.712 

Favus of the nail (favie onychomycosis) . . . . .714 

Tinea trichophytina .......... 719 

(A) Tinea circinata.722 

(B) Tinea tonsurans . . ..729 

Tinea kerion ......... 735 

(C) Tinea sycosis.737 

Precautions to be observed in the general management 
of tinea favosa and tinea trichophytina . . .742 

Tinea imbricata . 743 

Mycetoma.744 

Actinomycosis of the skin.747 

Tinea versicolor.750 

Myringomycosis.754 

Erythrasma . . . . . ..754 

Pinta disease.. . . .756 

2. Diseases due to Animal Parasites.757 

Scabies.757 

Demodex folliculorum . . . . . . . . .767 

Pulex penetrans.768 

Irritans.768 





























XX 


CONTENTS. 


PAGE 

Filaria medinensis.769 

Craw-craw. • 771 

Cysticercus cellulosae cutis.771 

Echinococcus.~72 

Distoma hepaticum.772 

Leptus.• ••••• 772 

Dipterous larvse in and beneath the human skin .... 774 

Ixodes . ..... 775 

Pediculosis.776 

Capillitii.776 

Corporis. • .779 

Pubis. 782 

Cimex lectularius. • • .784 

Culex pipiens .......... 786 

Protozoa and sporozoa.786 


ERRATA. 

Page 111, line 5 ; for “ seborrhocium,” read “ seborrhoicum.” 

Page 115, line 5 ; for “ dermatitis (eczema) seborrhoicum,” read “ dermatitis 
seborrhoica (eczema seborrhoicum)”. 













LIST OF ILLUSTRATIONS. 


FIG- PAGE 

1. Section of skin from the palm of the hand.18 

2. Subcutaneous fat-tissue.20 

3. Columnse adiposae.21 

4. Vertical section of skin after injection (from beneath) with Berlin blue 22 

5. Vascular and nervous papillae.23 

6. Scalp of a colored man—horizontal section.24 

7. Prickle-cells.26 

8. Pacinian body, after silver staining.' . 30 

9. Section of papilla containing a tactile body (from the skin of a finger) 31 

10. Transverse section of nervous papilla.32 

11. Section of hair-follicle during the formation of a new hair . . 35 

12. Hair-follicle in longitudinal section ....... 35 

13. Lower portion of hair-pouch from the lip of a kitten .... 37 

14. Transverse section of hair and follicle.39 

15. 16. Sebaceous glands of the second class from the alae of the nose . 41 

17. Coil of the sweat-gland ......... 42 

18. The sweat-pore traversing the epithelial layers of the skin ... 43 

19. Section of the skin from the palm of the hand.44 

20. Thin section of the skin of the finger removed at the site of a sweat- 

pore .46 

21. Vertical section of one-half of nail and matrix ..... 48 

22. Implantation of the nail at its border.49 

23. Irido-platinum needle.91 

24. Milium needle ..91 

25. Scarifying-spud.91 

26. Epilating-forceps ..91 

27. Piffard’s grappling-forceps.91 

28. Piffard’s cutisector.91 

29. 30. Dermal curettes ..91 

31. Hess’s glass pleximeter . ..92 

32. Comedo-extractor.92 

33. Cutaneous punch.92 

34. Massering-ball ..92 

35. Section of a comedo . . - -.123 

36. Cysts of the scalp.129 

37. Microphotograph of the bacillus scarlatinse.140 

38. Vertical section of pustule at the beginning of pustulation in variola 143 

39. Vertical section of one-half of an undeveloped pustule . . .145 

40. Autographism in urticaria ... .169 

41. Urticaria pigmentosa. (From a photograph.) ..... 171 












xxii 


LIST OF ILLUSTRATIONS. 


FIG. 

42. 

43. 

44. 

45. 

46. 

47. 

48. 

49. 

50. 

51. 

53. 

54. 

55. 

56. 

57. 

58. 

59. 

60. 
61. 
62. 

63. 

64. 

65. 

66 . 

67. 

68 . 

69. 

70. 

71. 

72. 


Papilloma, due to the ingestion of the iodin compound 

painting in oil.). 

Feigned eruption. (From a photograph.) . 

Vertical section of anthrax .... 

Section of anthrax ..... 

Malignant pustule bacilli and pus-corpuscles 
Longitudinal section of the third spinal ganglion of the r 
region, from a case of lumbo-inguinal zoster 
Vertical section of skin from a patch of psoriasis 
Molluscum epitheliale . 

Molluscous corpuscles . 

52. Varieties of cutaneous horns 
Vertical section of the summit of a pointed war 
Ichthyosis hystrix 
Ichthyosis hystrix, vertical section 
The Russian “ dog-faced man ” . 

Elephantiasis of the foot and leg 
Elephantiasis scroti 
Vitiligo in a negro boy 
Trichorrhexis nodosa 
Keloid . 

Multiple fibromata 
Large single fibroma 
Neuroma of the skin ; 


73. 

74. 

75. 

76. 

77. 

78. 

79. 

80. 

81. 

82. 

83. 

84, 

86. Bacilli of leprosy . 

87. Superficial papillary epithelioma of face 

88. Epithelioma, vertical section 

89. Cancer en cuirasse 


external appearance 
Microscopic structure of neuroma 
Lupus vulgaris of the face. (From a photograp 
Lupus vulgaris of the leg. (From a photograph 
Verruca necrogenica ..... 

Section of a lupus nodule .... 

Section of lupus of the face 
Lupus erythematosus of the face . 

Facial cicatrices of tubercular syphilodermata after twent 

of infection. 

Syphiloderma papulosum .... 

Vegetating condylomata of the vulva . 

Palmar syphiloderm. 

Ulcerative tubercular syphiloderm 
Syphilitic gummata of head and face . 

Syphiloma of the vulva with gummatous change 
Lee’s safety-lamp for fumigation . 

Lepra tuberculosa. 

Tubercular leprosy. (From a photograph.) 

Anesthetic leprosy with mutilating results. (From a 
Larynx of patient affected with lepra tuberculosa 
85. Larynges of lepers affected with lepra tuberculosa 


ght lumbar 


in labia 


(From a 


-five 


hotograp 


years 


nd clitoris 


191 

196 

213 

213 

216 

246 

259 

429 

430 
437 
442 
450 
453 
459 

477 

478 
491 
514 
525 
531 
531 

535 

536 
565 
569 
571 
580 
582 
593 

607 

612 

615 

616 
622 
624 
624 
645 

657 

658 
661 

663 

664 

665 
673 
679 
685 










LIST OF ILLUSTRATIONS. xxiii 

FIG. PAGE 

90. Sarcoma. 689 

91. Mycosis fungoides.693 

92. Achorion Schonleinii.714 

93. Epidermis invaded by trichophyton.725 

94. Hair invaded by trichophyton . . . . . . . .732 

95. Filaments and spores of trichophyton from the beard . . . 738 

96. Osseous lesions in mycetoma.746 

97. Microsporon furfur.752 

98. Microsporon minutissimum . . . . . . . .755 

99. Female acarus.758 

100. Acarian furrow.759 

101. Demodex folliculorum.767 

102. Leptus ..773 

103. Leptus autumnalis.773 

104. Acarus hordei.773 

105. CEstrus.774 

106. Larvae from body of child.774 

107. Pediculus capillitii.776 

108. Ova of head-louse.777 

109. Pediculus corporis.779 

110. Pediculus pubis.782 










LIST OF PLATES. 


Plate I. Nevus Lipomatodes. (From a photograph.) 


frontispiece. 


* 


Plate II. Acne-keloid of the Back. (From a photograph.) 


facing page 


Plate III. Malum Perforans Pedis, with Symmetrical Keratoma of the 
Palms and Soles. (From a water-color sketch.) 

facing page 


Plate IV. Congenital Warts. (From a photograph.) 


Plate V. Circumscribed Scleroderma. 


facing page 


facing page 


Plate VI. Elephantiasis Telangiectodes of the Upper Lip and Portions 
of the Face. (From a photograph.) 

facing page 


Plate VII. Multiple Fibroma of the Back. (From a photograph.) 

facing page 

Plate VIII. Xanthoma of the Hands, Elbows, and Knees. (From a 
photograph.) 


facing page 

Plate IX. Lupus Hypertrophicus of the Face. (From a photograph.) 

facing page 


Plate X. Large Pustulo-crustaceous Syphiloderm of the Scalp and 
Body. (From a photograph of a cachectic clinical patient.) 

facing page 

Plate XI. Tubercular Syphiloderm, Resolutive and Serpiginous. (From 
a photograph of a hospital patient.) facing page 


Plate XII. Mycetoma. 


372 

433 

439 

470 

478 

530 

538 

568 

619 

622 


facing page 745 



I. ANATOMY AND PHYSIOLOGY OF THE SKIN. 


The skin is the living envelope of the human bodv; it is closely 
associated with underlying structures, and by its situation is brought 
into intimate relation also with the external world. The skin is a 
complex, elastic, and sensitive organ, varying greatly in different 
conditions of climate, age, sex, health, and race; and varying also in 
the characteristics exhibited in different localities upon the same indi¬ 
vidual. Thus, in color, there is a wide range between the fair skin of 
the blonde and the black skin of the negro, between the rosy pink of 
the infant’s palm and the dark-brown hue of the genital region of the 
aged. The skin varies also in pliability and thickness, being delicate 
and lax over the eyelids, the lips, and the prepuce; and much thicker 
and more firmly attached over the palms and the soles. 

It is important to note that the appearance of the skin, even in con¬ 
ditions of health, also changes within appreciable limits. It is the 
exposed parts (such as the face) which the eye of the physician most 
frequently searches, and which betray evidence of mental emotions, 
physiological fluxes, sedentary or active habits of life, and fatigue or 
unusual conditions of vigor. 

Viewed externally, the skin is seen to be traversed by superficial 
and deeper furrows, dotted by numerous depressions representing the 
mouths of its follicles, and provided very generally with coarse or 
with fine downy hairs which in some parts are of sufficient growth to 
conceal the skin from view. This pilary growth serves not merely as 
an ornament of the body, but also as a protection to some of its regions 
most sensitive to thermal changes. 

By its extraordinary sensitiveness to different degrees of temperature 
and to the physical properties of the bodies with which it is brought 
into contact, the skin becomes, even when unaided by the eye, a valu¬ 
able means of preserving the human frame from external injury. This 
protective function is, in part, due to the horny character of its outer 
layer, as a consequence of which the loss of essential fluids and the 
ingress of noxious substances are equally restricted. 

One of the most important functions of the skin is the part it plays 
in regulating the body-temperature. The temperature-variations at 
its surface, modified naturally by the character and quantity of the 
clothing when such is worn, produce corresponding variations in the 
smooth muscles and contractile blood-vessels of the skin. By enlarge¬ 
ment or diminution of the lumen of these vessels, whether resulting 
directly from the action of heat or of cold at the surface, or indirectly 
through an effect upon the vaso-motor centres, large quantities of 
blood are brought to or removed from the superficies of the body. In 
one case the blood is cooled by evaporation at the body-surface; in the 

2 


18 


DISEASES OF THE SKIN . 


other, the loss of heat by such evaporation is greatly restricted. This 
process is materially influenced by acceleration or retardation of the 


Fig. 1. 



F m ui me uaiiu, magmnea iou ammeters: a, stratum corneum ; a', its 
superficial layer; b, stratum lucidum; c, stratum granulosum; d, stratum mucosum (rete); 
e, pars papillaris of the corium, loops of capillary vessels showing in vascular papillae ; f, pars reticu¬ 
laris of the corium, showing coarse interlacing connective-tissue bundles ; g, transverse section of 
the latter; h, double-contoured nerve-fibre passing to tactile body ; i, coil-glands ; k, ducts of coil- 
glands ; 1, sweat-pores passing to surface of epidermis; m, arteries of the skin terminating in 
capillaries; n, veins of the skin forming plexuses ; o, fat-cells, encompassed by capillary loops, in 
re ation with coil-glands; the capillaries of the latter are purposely omitted in the drawing • 

p, obliquely and transversely divided bundles of connective-tissue fibres of the corium and subcu¬ 
taneous tissue. 




ANATOMY AND PHYSIOLOGY OF THE SKIN 


19 


heart’s action, whether produced by moral or by physical causes. It 
is also modified by the occurrence of sweating, as a result of which 
heat in varying amounts is rendered latent, and either watery vapor 
escapes from the surface or sweat is exuded in drops, the aggregate of 
which may be several pounds in weight in the course of twenty-four 
hours. 

To a limited degree, the skin is capable of acting as a respiratory 
agent, eliminating carbonic acid gas with watery vapor, and possibly 
also absorbing oxygen in small amount. Its power of absorbing ali¬ 
ments, medicaments, and toxic substances has as yet but imperfectly 
been determined. Substances in liquid state are practically not ab¬ 
sorbed so long as the horny layer of the epidermis is intact. The 
loss of this external protective layer, however, permits tbe ready 
absorption of many liquids. Many gases are readily absorbed by the 
unbroken skin, as to a less extent are some fats and oils, as well as a 
few substances in a finely powdered state. Such absorption, when it 
occurs, is probably effected through the portal of a hair-follicle and 
the ducts of the cutaneous glands. 

The skin is provided with a natural unguent, by which, in a state 
of health, it is constantly anointed. The fatty and oily secretions of 
the skin are concerned, not merely in the anointing of the general sur¬ 
face and of the hairs, but also in the regulation of the body-tempera¬ 
ture, by preventing maceration of the tissues by the sweat. 

The complex organ which is called tc the skin” is essential to the 
life of the individual. The sexual, and possibly other organs of the 
human body, may have their functions arrested, or they may even be 
obliterated by destructive processes, and life still continue; but if all 
the functions of the skin were suspended for a sufficient period of time, 
the result would be fatal to human life. In its important relations 
alone to the complicated processes by which the heat of the body is 
maintained at a relatively fixed standard the skin exhibits its impor¬ 
tance to the general economy. It is thus seen to be, not an isolated 
membrane stretched mechanically over an artificial machine, but is one 
of several living and potential systems of the body, each system being 
in intimate union with all others. 

The integument of the body, when studied by the aid of the micro¬ 
scope, is found to be composed of several organic parts, which are: the 
subcutaneous connective tissue resting on the deeper structures of the 
body; then, more externally, the corium, or true skin; lastly, an outer¬ 
most coat, the epidermis or cuticle. Beside these parts, the skin con¬ 
tains oil-glands, sebaceous glands, hairs, nails, blood-vessels, lymph- 
vessels, muscles, pigments, and nerves. It will be instructive to study 
the deeper parts of the skin before those more superficially disposed, 
as their mutual relations will thus be made clearer. 

Subcutaneous Tissue. 

The subcutaneous tissue is differentiated from the corium between 
the third and the fourth month of foetal life. It is a structure serving 
a mechanical purpose as a receptacle for fat, and for the support of 


20 


DISEASES OF THE SKIN. 


vessels and nerves pacing from the tissue beneath to the corium, 
which lies next above it. It contains, also, coil-glands, some ot the 
hair-follicles more deeply seated than their fellows, and Pacinian cor¬ 
puscles. There is no distinct boundary-line between the upper limits 
of the subcutaneous tissue and the overlying corium, to which it pro¬ 
jects columnar masses of fat, extending obliquely to the coil-glands and 
the hair-follicles above, often with lateral, horizontally disposed pro¬ 
longations of similar shape. It is built up of loose connective-tissue 
bundles, prolonged from the aponeuroses, fascue, and the membranes 
lying: beneath. 

J © T7t/~i O 



Subcutaneous fat-tissue, the fat having been extracted by turpentine : B, bundles of fibrous 
connective tissue, carrying injected blood-vessels; C, capsules of fat-globules, with oblong nuclei. 
Magnified 500 diameters. (After Heitzmann.) 


The subcutaneous tissue is firmly attached to the skin over the 
extensor surfaces of the articulations, the palms, the soles, and the 
groins by short, coarse bundles, between which are single or multiloc- 
ular spaces lined with endothelia, secreting a mucoid fluid. These 
spaces are the bursse mucosae. Elsewhere, as in the eyelids, the penis, 
the scrotum, and the auricle of the ear, the attachment to the skin is 
by loose, delicate connective tissue, containing no fat-globules. All 
other fibrous tracts are arranged obliquely ; they admit, by their exten¬ 
sion, of various degrees of pliability, and inclose rhomboidal spaces 
containing more or less numerous fat-globules. These spaces are lobu- 
lated, are bounded by a delicate fibrous connective tissue, and are 
abundantly supplied with blood-vessels. This layer is termed the 
panniculus adiposus. 

The deposit of fat in the body is greatly reduced in all diseases pro¬ 
ductive of emaciation, but never wholly disappears in life. In cases 
of obesity, fat is deposited in excess of normal limits, and it may then 





ANATOMY AND PHYSIOLOGY OF THE SKIN. 


21 


be concerned in the production or the aggravation of disease. It is 
argely due to the greater or lesser volume of the panniculus adiposus 
that the natural outlines of the body are made to the eye graceful and 
attractive, or the reverse. 

The Corium. 

The Corium (Derma, Cutis Vera, or True Skin) is composed 
of bundles of fibres of connective tissue, whose decussations produce a 
dense felt-work, coarsest toward the subcutaneous tissue, upon which 
it rests interiorly, and finest in the outermost portion, which is in con¬ 
tact with the epidermis above. The bundles are composed chiefly of 
fibres of white fibrous tissue, but are accompanied by a varying num¬ 
ber of elastic fibres. Connective-tissue corpuscles are also present in 

Fin. 3. 





Vertical section of skin showing: a, epidermis; b, erector pili muscle; d, column® adipos®; 
c, coil-gland suspended in the column® adipos®; h, sebaceous gland ; p, horizontal prolongations 
of the column ; f, fibrous bundles of the corium; g, panniculus adiposus; k, band of fibrous tissue 
extending into the panniculus adiposus. (After Warren.) 

small numbers. Thomsa and other observers describe a “ cement- 
substance/ ’ or basis-substance, surrounding all the fibres and holding 
the various elements of the skin together. Other observers, however, 
deny its existence. The derma is rich in blood-vessels and capillaries, 
especially in the papillary layer, and contains many nerves, nerve- 
endings, and terminal nerve-organs. It further contains lymphatics, 
smaller muscle-fibres, hairs, sweat-glands, and sebaceous glands. 

Corresponding with their anatomical structure the upper and lower 
portions of the derma are called respectively the “ papillary layer ” 
and “ reticular layer.” There is no sharp dividing-line between the 
two layers, the pars reticularis passing gradually into the pars papillaris 
above and into the subcutaneous tissue below. 





DISEASES OF 'I'HF SKIN. 


oh 

an 

mid llio layers w1 1 i<di surround then* duets. 



Kiel, 4, 


h 


h 



Vortical Motion ofikln aflor lnjouttnu (from Uneath) of areolar tluuo with Berlin blue: 

<i, opltlormU; /, corlinn ; g, pannloulua atllpomii; /», Mbacoou* gland. (After Waiiubn.) 

Pans IIetioulahim, The reticular layer of tho oorium in made up, 
ns Inis boon soon, of interlacing connective-tissue bundles, with inter¬ 
spaces increasingly larger from without inward. Tho fineness of tho 
bundlos decreases, in tho same way, from within outward, being finest 
whom tlu* ininuto papilla) of tho oorium project into the rote, and 
ooarsost near tho subcutaneous tissue. 

PAHS Paimllauis. r Pho papillary layer of the oorium lies in con¬ 
tact with tho rote above, and is connected below with the deeper retic¬ 
ular portion of the truo skin, llotwoon tho rote and the papilho of 
tho derma a hyaline substance is interposed which IJnna believes to be 
identical with tin* so-oalJed i( oenumt-substanoe’’ described by some 
authors as surrounding and separating the librilheof tho oorium. Tho 
basal membrane, ouoo thought to ho stretched between the rote muoo- 
sum of tho epidermis and the papillary layer of the oorium, cannot bo 
demonstrated to exist. 

Viewed obliquely, with an amplification of about throe hundred 
diameters, it will be seen that long and slender filaments from the 
prickle-eells of the mucous layer of the epidermis encircle in a spiral 
direction both nervous and vascular pupil he. At the apices of the 
latter these threads completely surround the connective-tissue fibres. 

The name of this portion of the derma is intended to describe its 
chief characteristic, the existence of numerous digital prolongations of 
tho oorium, made up of delicate connective-tissue fibres, which do not 


ANATOMY AND PHYSIOLOGY OF THE SKIN. 


23 


interlace, and which are abundantly provided with nuclei. The papilla* 
spring each from a single, or several from a common, ovoid base; their 
bulbous, conical, or blunt apices reach into the rete, which also dips 
down between them. The papillae differ in size in different parts of 
the body,, and also in their disposition and shape, being in places 
arranged in linear series, and in other in concentric whorls, with defi¬ 
nite centres, thus producing crossing-furrows, visible to the naked eye 
as markings upon the outer surface of the epidermis. 

Fig. 5. 



Vascular and nervous papillae: a, vessel; b, nervous papilla , c, vessel; d. nerve-fibre; e, corpus- 
culum tactus; /, transversely divided nervous filaments; g, epithelia of rete. (After Biesiadecki.) 

In horizontal sections of the skin the papillae, being transversely 
divided, appear as circular or ovoid areas, in which can be recognized 
centrally a transversely or obliquely divided capillary loop. Between 
these areas is seen the interpapillary reticulum of the mucous layer. 

According to Unna, who bases his statements upon the wide variation 
between the largest sized papillae and their entire absence in some 
regions, the papillary layer of the corium represents merely “ an 
extremely variable border-phenomenon.” Certain it is that the growth 
of the rete downward and of the corium upward results in mutual 
effects of pressure and counter-pressure whose equilibrium is constantly 
adjusted by the mechanical and vital necessities of such union. 

When the papillae are completely exposed, after removal of the over- 
lying so-called “ cement-substance” and of the epidermis above, their 
exterior surface is seen to be uniformly marked with series after series 
of alternating furrows and ridges of exceeding delicacy, and more or less 
concentrically disposed. Into the grooves are admitted corresponding 









24 


DISEASES OF THE SKIN. 


dentations that can be recognized on the undersurface of the layer of 
epithelial cells next the corium. They may, however, be the furrows 
left after separation of the long prickles wrapped about the papillae and 
traceable to the mucous layer. 

Two varieties of papillae are distinguished—the vascular and the 
nervous; the former contain the terminal loops of a minute artery and 
vein, and the latter the terminations of medullated nerve-fibres. 

The greater number of tlie papillae are of the vascular variety, being 
traversed by a vertically disposed loop of vessels, consisting of an arte¬ 
rial and a venous capillary. The office of the vascular loops is evi¬ 
dently not merely to supply nutriment for the epidermis above, but 
also to provide for the cooling of the blood when brought in large 
quantities to the surface of the body. Occasionally, two or more of 
such loops can be recognized in a single papilla. 

The nervous papillae contain the tactile corpuscles, which subserve 
an important purpose in providing for the sensibility of the integument. 
The tactile corpuscles are described in connection with the nerves of 
the skin. Ultimate terminations of nerves can be recognized in the 
vascular papillae, and at times minute vascular loops can be seen in the 
papillae largely occupied with the corpuscles of touch. 


The Epidermis. 

The Epidermis (Scarf-skin, or Cuticle) is the most external of 
the several membranes of the body, being in close contact on one side 

Fig. 6. 



Scalp of a colored man-horizontal section: R , rete mucosum; Pi, row of columnar epithelia 
(cut obliquely) supplied with dark-brown pigment-granules; Pa, papilla, cut transversely 
D, derma. Magnified 500 diameters. (After Heitzmann.) 


with the corium, or true skin, and exposed on the other to the atmos¬ 
phere by which it is surrounded. The latter surface is therefore rela¬ 
tively drier, while the former is constantly moistened by fluids from 
the vessels which ramify beneath it. 


ANATOMY AND PHYSIOLOGY OF THE SKIN. 


25 


ISo genetic relation can be established between the epidermis and the 
corium, notwithstanding their intimate union and mutual relationship. 
The epidermis is developed from the ectoderm, the corium from a 
superficial layer of the mesoblast, Their behavior both in health and 
in disease is marked by the widest difference. 

The epidermis differs greatly in thickness in different portions of 
the body, for example, that of the palms and soles exceeding, in ver¬ 
tical section, that which covers the dorsum of these same organs and 
that protecting such sensitive parts as the eyelids, lips, temples, and 
prepuce. 

The epidermis is composed of the following layers, named in order 
from within outward: the stratum mucosum, the stratum granulosum, 
the stratum lucidum, aud the stratum corneum. Each of these strata, 
or layers, is histogenetically derived from the one which is deeper in 
situation. 

The Stratum Mucosum (Mucous Layer, Prickle-layer, Rete 
Mucosum, Rete Malpighii or Malpighianum) is the deepest of 
the epidermal layers, and rests upon the corium below. The corium 
is intimately united with it by a series of interdigitations which are 
commonly described as prolongations of the derma into the substance 
of the rete, but it is equally true that the rete sends down prolonga¬ 
tions into the derma. The two, in the need of an intimate union to 
resist friction and to insure vascular supply, are thus closely locked 
together. 

The stratum mucosum is built up of nucleated epithelial cells, poly¬ 
hedral in outliue and diffusely colored. These cells are masses of 
granular protoplasm, living matter, which by their relation to one 
another form a protoplasmic network enveloping the entire surface of 
the body and lining all channels and cavities in direct or indirect con¬ 
nection with the surface. These elements are flattened by reason of 
their apposition, and are separated from one another by an intercellular 
substance, which has been described as “ cement-substance.” There 
is, unquestionably, a system of channels between the epithelia, by which 
the fluids of nutrition are conveyed from cell to cell. All are, how¬ 
ever, uninterruptedly united by delicate spokes, known as prickles, 
spines, or thorns. The living matter, which produces a delicate retic¬ 
ulum within each protoplasmic body, its points of intersection being 
termed nuclei, nucleoli, and granules, furnishes the already described 
filaments, which thus produce continuity through all the living layers 
of the epithelial elements, as well as through the underlying layers of 
the connective tissue. The epithelia are unprovided with either blood- 
or lymph-vessels; but, when living, are supplied with a large number 
of nerves, which, in the shape of very minute beaded fibres, traverse 
the intercellular substance, and which are in direct communication with 
the reticulum of living matter within the protoplasmic bodies them¬ 
selves., 

The living masses of protoplasm, just described, play the most im¬ 
portant part in all the pathological and physiological processes observed 
in the skin. It is probable that, in the embryo, all the appendages of 


26 


DISEASES OF THE SKIN. 


the skin are formed directly by their assimilative and reproductive pro¬ 
cesses; and it is certain that in health and in disease they furnish the 
organic matter of all secretions. 


Fig. 7. 



Prickle-cells from a condyloma (magnified about 625 diameters): a, cavity of cell-nucleus ; 
b, nucleus; c, nucleolus; d, prickles—these are greatly developed on the protoplasm of the cells. 
The dots on the surface of the protoplasmic mass represent the appearance of the prickles when 
directed toward the eye of the observer. Some of the protoplasmic threads are seen passing from 
one cell to another. 


Next the corium is a layer of cells, columnar in form, and arranged 
with their long axes nearly at right-angles to the plane of that portion 
of the corium upon which they are superimposed. More externally 
the cells are rounded or cuboidal in shape, with large, distinct nuclei. 
They are not arranged in definite strata except in the very outermost 
layers, where the cells are somewhat flattened and elongated. Between 
, the cells in the deeper layers outwandered leucocytes may at times be 
recognized. 

The Stratum Granulosum, or Granular Layer of the epi¬ 
dermis, is built up of one or two, rarely more, rows of horizontally 
disposed granular bodies, united to one another by short, broad threads. 
Between these bodies the intercellular spaces are so contracted that 
nutritive fluids cannot easily filter outward; and the nuclei of the cells 
are usually shrunken. These have carefully been studied by Banvier, 
Kolliker, Waldeyer, and others. According to these observers, the 
roundish granules which give this layer of epithelium its peculiar name 
and appearance consist of eleidin or kerato-hyalin, a substance essen¬ 
tial to the process of cornification in the elements making up the horny 
layer of the skin, nails, etc. These granules begin to appear in the 
neighborhood of the nuclei of some of the large prickle-cells in the 
rete, but they are best studied in the granular layer, whose cells are 
often completely filled with them. According to Unna, the color of 
the skin in the white races alone depends upon this layer. 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 


27 


The Stratum Lucidum, or Septum Lucidum, of Oehl, lies im¬ 
mediately above the stratum granulosum, and appears under the micro¬ 
scope as a delicate, brightly colored line, consisting of two or three 
rows of transversely disposed, glistening epithelia, differing in trans- 
lucency from those situated on either side. The stratum lucidum thus 
marks with tolerable distinctness the boundary-lines of the rows of 
cells above and below it. Its epithelial bodies have suddenly lost the 
refractive, shining grannies of kerato-hyalin, conspicuous in the stratum 
granulosum below. These granules are generally supposed to have dis¬ 
appeared in consequence of their solution in the protoplasm of the cell- 
body, which has thus acquired an added brilliancy and clearness. 

The Stratum Corneum, or Horny Layer of the epidermis, is 
its outermost and widest layer, extending from the stratum lucidum 
below to the external environments of the body. In its lower portion, 
the polygonal plates of which it is composed indicate very clearly their 
relationship to the cells in the prickle-layer. The nuclei appear in 
places only as shrivelled and inconspicuous relics of the protoplasmic 
threads. Occasionally, on the edges, rudiments of the prickle-threads 
may still be recognized. More externally, the dried, lifeless, horn¬ 
like plates of which this layer is composed become mere cornified 
shells, generally lying in horizontal strata, and becoming more curled 
and wrinkled as the surface of the skin is reached, often being imbri¬ 
cated, but preserving the polygonal outlines of epithelia relieved of 
the forces of pressure and counter-pressure exerted in the deeper parts 
of the epidermis. These elements are rarely pigmented, save in the 
case of the negro, in whom the intense staining of the deepest parts of 
the mucous layer is to a degree spread to the external strata. This 
staining in the colored races is produced by granules of pigment 
arranged about an unaffected nucleus in the prickle-cells. 

According to Unna, after digestion with pepsin and trypsin, it is 
seen that the horny cells are connected by more or less persistent 
threads, visible after more prolonged digestion as a large-meshed retic¬ 
ulum, with strands formed from a double row of cornified filaments 
united by short horny bridges. 

Epitrichial Layer. Welcker, 1 Minot, 2 and Bowen 3 have de¬ 
scribed a layer of large cells, with round nuclei much larger than those 
of the epidermal layers beneath, covering the entire body of the human 
embryo during the early months of its existence. This layer, histo¬ 
logically, is quite distinct from the outer cells of the stratum corneum 
and corresponds with the epitrichium of certain animals. It usually 
disappears before the sixth or the seventh month of uterine life. 

Blood-vessels. 

The Arteries and Veins supply the skin from subcutaneous 
branches which penetrate the underlying fasciae, and proceed by sub- 

1 Ueber die Entwickelung und den Bau der Haut und der Haare bei Bradypus. Halle, 1854. 

2 American Naturalist, June, 1886. 

3 Anatomischen Auzieger, iv. Jahrgang (1889), Nr. 13 u. 14; and Journ. Cutan. and Ven. Dis., 
1895, p. 485. 


28 


DISEASES OF THE SKIN. 


division to be distributed to all portions of the integument below the 
epidermis, the distribution being especially abundant about the glands 
and follicles of the skin, and the inferior and superior parts of the 
corium. They are always more abundant upon the flexor than upon 
the extensor faces of the extremities. Just beneath the papillary layer 
of the corium there is a minutely ramifying plexus of fine capillaries, 
the loops of which extend into the papillae above. This and the coarser 
plexus in the deeper portion of the derma are so well defined that they 
might be designated as superior and inferior partes vasculares of the 
corium. A third vascular tissue is found in the subcutaneous connec¬ 
tive tissue where the vessels are numerous. 

The arterioles which supply the sweat-glands-surround the coils of 
the latter in a delicate basket-like plexus, and terminate in two or three 
veinlets, one of which always accompanies the duct of the gland upward 
as far as the papillary layer, where it anastomoses with the vessels of 
that part of the skin. The ascending arterioles supply the sebaceous 
glands and hair-follicles, and, breaking up into smaller and yet smaller 
branches, finally furnish a single or a double capillary loop to each 
papilla. The capillaries of the papillary layer anastomose freely with 
those transversely arranged in the upper portion of the hair-follicles, 
from which loops also pass to the sebaceous glands. The hair-papilla 
has a vascular supply similar to that of each of the other papillae of 
the corium. 

Unna divides the vessels distributed to the skin into the papillary 
system and the system of the coil-glands and fat-tissue. The first 
system includes the ascending loops which traverse the vascular papillae, 
and the branches supplying lower portions of the corium. The second 
system embraces the vessels running upward to the coil-glands and 
downward to the fat-tissue. In the papillary vascular system the 
arteries are narrow and the veins wide. Each of the vessels consists 
merely of an endothelial tube augmented, as the subcutaneous tissue is 
reached, by both media and adventitia. According to Hoyer, there is 
a singular duplex arrangement of vessels in the distal phalanges of 
both fingers and toes, in consequence of which there is a distinct com¬ 
munication between the arteries and veins. Other observers deny the 
existence of such anastomosis. 

Vaso-motor nerves are twined around these vessels in all their ram¬ 
ifications. The whole vascular system, as thus arranged, plays a most 
important part in all the healthy and morbid processes which occur in 
the skin, as Avell as in the sudden physiological changes distinguish¬ 
able to the eye in the phenomena of blanching and blushing. 


Lymphatic Vessels. 

The skin in all its parts is provided with a system of lymphatic 
channels, designed to subserve the necessities of the important pro¬ 
cesses of absorption, and traversed by lymph whose currents are con¬ 
tinuously directed to the large vessels of the structures beneath the skin. 
Unna divides these channels into : first, juice-spaces, provided or not 


ANATOMY AND PHYSIOLOGY OF THE SKIN. 


29 


with independent walls, usually without, and not freely communicat¬ 
ing with the endothelium-lined vessels; second, lymphatic vessels 
proper, which communicate directly with the blood-vessels. 

The juice- or lymph-spaces separate the epithelial bodies which make 
up the stratum mucosum of the epidermis, and they also extend be¬ 
tween the protoplasmic threads or prickles that unite them. Such 
conduits may be regarded either as delicate excavations in the so- 
called “ cement-substance ” between the epithelia, or as irregular 
channels in a softish, viscid, albuminoid, and readily coagulable sub¬ 
stance existing between the protoplasmic threads. In the latter case 
these spaces would be comparable to the impressions made by thrusting 
at random a pencil into a mass of soft putty. At times this intercel¬ 
lular substance seems capable of obstructing the conduits by which it 
is tunnelled. These juice-spaces exist in the papillae of the corium, 
and encircle the several glands, hair-follicles, and nail-beds of the skin. 
They also sheathe the connective-tissue fibrillse of the corium and sur¬ 
round the fat-cells. 

The lymphatic vessels are relatively few, but they form a continuous 
meshwork with transversely and vertically disposed branches supply¬ 
ing all parts of the skin below the epidermis. The juice-spaces com¬ 
municate with these vessels in the papillary portion of the corium 
through minute orifices in the vascular walls, the vessels themselves 
being here represented by blind terminal loops. As these vessels pass 
to the deeper port’ons of the corium and below it they increase in size. 
The current of the lymph flows from the papillary apices in every 
direction to all parts of the rete, like the currents in the delta of a 
river, a reflux occurring at the lower limit of the interpapillary depres¬ 
sions of the rete downward, possibly through the sweat-pores which 
traverse the epidermis at these points. Thence the current flows 
freely downward to the lymphatic vessels in the corium, but the stream 
from the juice-spaces about the coil-glands and fat-tissue is retarded by 
reason of a more restricted communication with the lymphatic vessels 
below. In consequence of the retardation due to this anatomical pecu¬ 
liarity the formation of fat by filtration is facilitated. 


Nerves. 

Non-medullated and medullated nerve-fibres, each in places being 
substituted for the other, are supplied to the skin from horizontally 
disposed bundles of nerve-twigs in the subcutaneous tissue. These 
fibres traverse the corium in connection with the blood-vessels, and 
become finer as they ascend, until they form a subepithelial plexus 
just below the epidermis. 

Exceedingly delicate Non-medullated Fibres penetrate in great 
abundance to the epidermis between the epithelia. Here, traversing 
the intercellular substance by the side of the juice-spaces, they either 
terminate between the prickle-cells as ultimate bulbous terminations 
of fiuely beaded fibrillse, or they penetrate the epithelia themselves 
in pairs. Each prickle-cell is supplied with a pair of these beaded 


30 


DISEASES OF THE SKIN. 


filaments, which may be either applied to the nucleus of the cell, or be 
seen to encircle the nucleus more or less completely. Above the 
stratum granulosum these nervous threads cannot be recognized. 

Similar nerve-filaments are supplied to the sheaths of the hairs and 
the ducts of the coil-glands. It is by means of these numerous and 
delicate fibres that the perception of sensation in the skin is accom¬ 
plished. 

Motor filaments, discovered by Thomsa, are also distributed to the 
sheaths of the blood-vessels, in which they are finally lost. Other 
motor filaments supply the muscles, and trophic nerves are distributed 
to all the secreting-organs of the skin and to all its protoplasmic 
formations. 

The Medullated Nerve-fibres of the skin have carefully been 
studied by Robinson . 1 According to this observer, one or several 
loops of such fibres pass upward into the papillae, and then turn back¬ 
ward to the subpapillary region. Some of these fibres, after such 
reversion, again ascend to an adjacent papilla; others are supplied to 
the Pacinian and tactile corpuscles. 

The Pacinian Corpuscles, named from the anatomist Pacini, 
also called Corpuscles of Vater, exist subcutaneously only upon 


Fig. 8. 



Pacinian body, after silver-staining, Section of Pacinian body, from a duck’s bill • 

showing superimposed endothelial g.l.^ lamellar envelope; g.h., hyaline zone of 
layers. (After Renaut.) the lamellar envelope; bt, terminal bulb of 

the nerve; g.p., n.g.p., layer investing the 
cavity of the body. (After Renaut.) 

nerves intended for cutaneous supply; they are small, oval bodies, two 
or more millimetres in diameter. Each corpuscle consists of a series 

i A Manual of Dermatology, by A. R. Robinson, M.D., etc. New York, 1884. 








31 


ANATOMY AND PHYSIOLOGY OF THE SKIN 

°f concentric, nucleated, vascular capsules, arranged after the manner 
ot the capsules of the onion, more closely united at the periphery than 
at the centre, and surrounding a protoplasmic core. The medullated 
nerve to which the body is attached gradually loses its myeline envel¬ 
ope, and terminates in the centre of this core, after traversing the 

Fig. 9. 



Section of a papilla still covered by a portion of the stratum mucosum and containing a tactile 
body (from the skin of a finger). The corpuscle of Meissner is seen to consist of minute lobules, 
made up of a homogeneous protoplasm, with numerous oval nuclei and nervous fibrillse wound 
in a spiral direction about the mass of the corpuscle. The extension of the fibrillse to the mucous 
layer is shown. The sources of the nerve-filaments are demonstrated to be: (1) the axis-cylinders 
of one or two double-contoured nerve-fibres, splitting into their original fibrillse on arriving at the 
corpuscle, winding about the latter in characteristic spirals, and passing to the palisade-layer of the 
prickle-cells of the rete, between which, on account of the long prickles of the latter and the gen¬ 
eral resemblance of the two in thickness and contour, it is difficult to trace them further; (2) fila¬ 
ments from another double-contoured nerve-fibre (h) pass directly to the inferior layer of cells in 
the rete without establishing relations with the tactile body ; (3) fibrillse derived from the network 
of nervous fibrillse in the pars papillaris of the corium (K), also passing more or less directly to the 
stratum mucosum. a, cells of the rete; b, prickles of the latter; c, body of papilla ; d, nuclei 'of 
connective tissue forming papilla; e, protoplasmic part of the tactile body with its nuclei ; 
/, fibrillse of the corpuscle ; g, double-contoured nerve-fibres directly supplying the rete ; k, nervous 
fibrillse derived from the network in the pars papillaris ; l, nervous fibrillse entering the epidermis 
between the rete cells, leaving the corpusculum tactus at m. 

greater part of its axis, in one or several, minutely club-shaped, nerve- 
filaments. The myeline sheath is lost in the tissue of the concentric 
capsules. According to Ranvier, the nerve may, after supplying one 
capsule, penetrate a second, or even a third. In such cases the nerve 
regains its sheath as it issues from the corpuscle at its opposite pole. 







32 


DISEASES OF THE SKIN. 


Robinson believes that the nerve forms a plexus or loop within the 
corpuscle, and leaves it at one of its poles. 

The precise function of the Pacinian corpuscle is unknown. Its 
connection with the tactile sense is suggested by its location, since these 
bodies are most numerous in the subcutaneous tissue of the nipple, the 
penis, the digits, and in parts similarly sensitive. These corpuscles 
bear an evident analogy to the organ of vision, each body having a 
capsular character; each being provided with a special nerve-filament, 
which enters the corpuscle at one pole; each also receiving its impres¬ 
sions at the extremities of the capsule opposite that where it receives 
its nervous supply. 

According to Krause, the Pacinian corpuscles are concerned in the 
appreciation of impressions produced by pressure and traction. 
Whether specially concerned in the distinguishing of sensations orig¬ 
inating in heat, cold, moisture, pressure, traction, or weight, it is evi¬ 
dent that they contribute but little, if at all, to the reception of 
ordinary impressions upon the skin, and, as yet, they are not known 
to play any part in cutaneous diseases. 

The Tactile Corpuscles (Corpuscles of Meissner, or of Wagner) 
are other oval-shaped bodies found in about one in four of the papillae 
in the pars papillaris of the corium. They are each composed of from 

Fig. 10. 



Transverse section of nervous papilla surrounded by cells of the stratum mucosum : a, proto¬ 
plasmic lobules of the corpusculum tactus ; b, nervous fibrillas spirally wound about the latter; 
c, transverse section of double-contoured nerve-fibres; d, cavity of nucleus, out of focus. 

one to three capsules. Minute lobules of a homogeneous protoplasm 
with oval nuclei are found in each. They receive medullated nerve- 
fibres and are made up of closely compressed, flat, connective-tissue 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 


33 


fibres with minute nuclei, which are so packed together as to form 
a spindle-shaped mass, occupying the greater part of the papilla in 
which each is found. A somewhat denser connective-tissue capsule 
encloses each. The myeline sheath of the nerve-fibres is lost in the 
fibrous tissue of the corpuscle. Externally viewed, they seem to be 
trausversely striated. 

The axis-cylinder of the nerve-filament distributed to each divides 
into numerous delicate nerve-threads which in part encircle the cor¬ 
puscle and also penetrate within. According to Robinson, each corpus¬ 
cle is provided with an afferent and efferent nerve, the former approach¬ 
ing the corpuscle from the subpapillary region and entering at or near 
its base. Occasionally the afferent fibre is furnished by an adjacent 
papilla. As the filament that enters the corpuscle frequently divides, 
two or more efferent fibres may then escape from it. Afferent fibres 
reach the rete above after encircling the tactile corpuscle; others, side 
by side, arrive at the rete without coming into contact with the former. 

The discovery of nerve-filaments in and among the epithelia of the 
epidermis in such abundance as to provide fully for tactile sensation 
in the skin, leaves the exact function of these corpuscles in partial ob¬ 
scurity. There can be little doubt, however, as to their association 
with the perception of certain qualities of foreign bodies with which 
the skin may be brought into contact. 


Pigment. 

The hue of the living integument is due in part to the degree of 
vascularity and distention of the vessels in the corium, and in part 
also to pigmentation of the epidermis. This pigmentation depends 
upon a distinct and uniform coloration of the epithelia, chiefly those 
found in the lower strata of the epidermis, and also to minute granules 
of pigment entangled in the reticulum of living matter in the same 
part. Extreme variation in the distribution of pigment is noticeable 
both in health and in disease, and in individuals and races, being at 
times proportioned to climatic and similar influences. This fact is well 
illustrated by the wide range between the flaxen-haired, pink-eyed 
albino, and the blackest specimens of the negro, each, with small 
exception, being of African descent. 

It has already been noted that in the colored races the pigment may 
stain the epithelial cells and their nuclei as high as the granular layer; 
and that to this layer only is due the peculiar color of the skin of the 
white races. Pigment is not normally found either in the horny layer 
of the skin or in the subepithelial tissues. Waldeyer claims to have 
recognized it in normal connective tissue. 

The relation existing between the two sources of skin-coloration, 
viz., the blood and pigment, is interesting and suggestive. The unaided 
eye, looking at the outer surface of the body, makes little distinction 
between these two color-sources. It is indeed probable that the pig¬ 
ment originates from the coloring-matters of the blood. It is certain 
that solar heat exerts a manifest influence upon both, and that in 

3 


34 


DISEASES OF THE SKIN. 


extravasations of blood into the substance of the skin every shade of 
color that can be detected in the spectrum may at times be distinguished. 


Muscles. 

Striated Muscular Fibres extend from the subcutaneous tissue 
into the derma; in the case of man they are found chiefly upon the face 
and neck, where they are the analogues of more powerful skin-moving 
muscles possessed by several of the lower animals. Some, as those 
in the region of the face, serve to give expression to mental emotion 
by the production of movements in the features. 

Non-striated Muscular Fibres exist either as minute oblique 
fasciculi in connection with the glands and follicles of the skin; or as 
annular bands, such as those which surround the nipple; or as radiat¬ 
ing and more or less parallel rods, such as antagonize the orbicularis 
in the lids. 

The Arrectores, or Erectores, Pilorum are muscles found 
usually in connection with the hair-follicles. They originate by minute 
multiple fasciculi from the papillary portion of the corium, and are 
inserted at several points into the outer layer of several adjacent hair- 
follicles, just above the plane of the apex of the hair-papilla. Their 
general direction is oblique, and their muscle-bundles are embraced and 
traversed by elastic fibres which form a dense network about them. 
Elastic threads also connect them intimately with the connective-tissue 
bundles of the corium, and serve as tendons at either extremity of 
each muscular fasciculus. 

The muscles, by virtue of their oblique direction and mode of attach¬ 
ment, include in the angle subtended by their muscular fibres the 
sebaceous glands connected with the hair-follicles. It follows, there¬ 
fore, that by their contraction they can aid in the expulsion of the seba¬ 
ceous secretion formed in the gland; but their intimate union with 
the elastic tissue, which is evenly aud generally distributed throughout 
the framework of the corium, results in their discharge of a still more 
important function in connection with the regulation of the body- 
temperature. Their anatomical connections are such that contraction 
of the arrectores pilorum serves to approximate several of the papillae 
of the corium, the hair-papilla being in this view regarded as one of 
such cones. Thus, by their contraction the sebaceous secretion may 
be extruded, or, as is more particularly exhibited in the lower animals, 
such hairs as the bristles of the boar may be erected. But by virtue 
of direct compression exerted upon the skin the blood may be driven 
from the surface in a centripetal direction and its cooling to a great 
degree prevented, as in the well-known phenomena resulting in the pro¬ 
duction of the cutis anserina or “goose-flesh.” The reverse of this 
naturally follows when the muscles expand under the influence of 
external heat. 


ANATOMY AND PHYSIOLOGY OF THE SKIN. 


35 


Hairs. 


Hairs are cylindrical, elongated, and pointed epithelial filaments, 
derived from the epidermis, and obliquely implanted in depressions in 


Fig. 11. 



Section of hair-follicle during the formation 
of a new hair: a, external and middle root- 
sheaths ; b, vitreous membrane ; c, papilla, with 
vascular loop; d, external root-sheath ; e, in¬ 
ternal root-sheath ; /, cuticle of hair-follicle ; 
g, cuticle of hair; h, i, young hair ; l, bulb of 
old hair; k, debris of external root-sheath of 
hair recently expelled. (After Ebner.) 


Fig. 12. 



TO 


Hair-follicle in longitudinal section: a, 
mouth of follicle ; 6, neck; c, bulb; d, e, der¬ 
mic coat;/, outer root-sheath, inner root- 
sheath ; h, hair; k, its medulla ; l, hair-knob; 
to, adipose tissue ; n, hair-muscle ; o, papilla 
of skin ; p, papilla of hair ; s, rete mucosum, 
continuous with outer root-sheath ; ep, horny 
layer; t, sebaceous gland. 


the rete and corinm, known as u hair-sacs/’ or “ hair-follicles. 

are found on all the superficies of the body except on the palms and 





















36 


DISEASES OF THE SKIN. 


soles, the dorsum of the distal phalanges of the hands and feet, and 
the skin of the penis. Hairs occur in three tolerably distinct classes: 

There are the line downy hairs, or lanugo, covering the. face, the 
trunk, and the limbs; the long soft hairs, such as those, implanted 
upon the scalp, the pubes, and the axillae; and the short hairs, includ¬ 
ing the soft varieties seen upon the brow and the stiff hairs of the 
eyelids. 

The hairs are first developed in the third month of foetal life, when 
a short epithelial cone is formed, whose base is gradually surrounded 
by connective-tissue cells, and finally indented from below by a rudi¬ 
mentary hair-papilla. Gradually the tip of the rudimentary hair 
perforates the primitive hair-cone, and becomes a mature filament. 

At about the period of birth, sometimes earlier, occasionally later, 
the “ bed-hairs,” as they are called by Unna, are replaced by papillary 
hairs. The term bed-hair is applied to primary hairs unprovided with 
papillse, and implanted in shallow follicles from the sides of which 
productive epithelial offshoots have been sent out. Usually at the end 
of foetal life these bed-hairs have been for two months growing out of 
the hair-bed, or that part of the epithelium found in the central part 
of the hair-sac. 

In studying the mature hairs the parts to be considered are the 
hair-follicle, and the bulb, shaft, and point of the hair. 

Hair-follicle. The hair-follicle is a sac-like depression in the 
corium, in which depression the hair-filament is implanted bv its bulb, 
and there firmly secured. The direction or set of this follicle is always 
at an oblique angle with the plane of the cutaneous surface upon which 
it opens; and thus is determined the set of the hairs, which is always 
fixed, and at a similar angle. Viewed as a whole, the integument of 
the body over its entire area exhibits determinate whorls of both short 
and long hairs with definite centres, such as those which may be recog¬ 
nized at the vertex of the scalp, the centres of the lips, the umbilicus, 
etc. By this disposition the symmetrical appearance of the hairy parts 
is preserved, and, as a consequence of the same provision, physiological 
loss of the hair of the head is not productive of deformity, but rather 
adds dignity to the aspect of the elderly man. 

The hair-follicle embraces the lower two-thirds of that portion of 
the hair which is imbedded in the skin, together with the envelopes of 
the latter, termed the hair-sheaths. Above the sebaceous glands the 
limits of the hair-follicle are lost in the papillary layer. It is consti¬ 
tuted of the connective tissue of the corium in three layers: an exter¬ 
nal, longitudinal, fibrous layer; a middle, transverse layer; and an 
internal, homogeneous, or vitreous layer. At the base of the sac a 
fibrous pedicle may often be traced as low as the subcutaneous tissue. 

If the hair-pouch were made artificially by thrusting into the skin 
from without inward a blunt-pointed pin before which the tissue was 
gradually pushed, it is evident that the external layer, the stratum cor- 
neum, of the epidermis would be the first depressed, and finally cover 
the inner surface of the pouch. This represents the inner root-sheath 
of the hair. Next to this the pin would carry before it the mucous 


ANATOMY AND PHYSIOLOGY OF THE SKIN. 


>')7 


layer of the epidermis, which then would form the outer root-sheath 
of the hair. Outside of both would lie the connective tissue of the 
corium; this is the hair-follicle. 


Fig. 13. 



Lower portion of hair-pouch from the lip of a kitten : F, follicle; T, transverse section of con¬ 
nective-tissue bundles of derma ; M, arrector pili muscle; IS, inner root-sheath ; OS, outer root- 
sheath ; P, papilla; C, cuticle; R, root of hair; H, hyaline, or so-called “ structureless ” membrane. 
Magnified 500 diameters. (After Heitzmann.) 

The Outer Root-sheath, or, as some prefer to call it, the “ prickle- 
layerof the hair-follicle, accompanies the involutions of the stratum 
corneum and the stratum granulosum from without into the funnel- 
shaped neck of the hair-pouch, as far as the openings of the ducts of 
the sebaceous glands. There, abandoned by the two other layers of the 
epidermis, the root-sheath is thinned in proportion as the papilla, which 
rises from below and which it closely surrounds, increases in size. It 
thus forms a hollow cylinder traversed by the hair and its envelopes, 
with a relatively wide, external, funnel-shaped opening, only partially 
filled by the shaft of the hair, and a narrower opening within, which 
embraces the neck of the hair-papilla. 




38 


DISEASES OF THE SKIN. 


The Inner Root-sheath, or, as Unna prefers to call it, the 
“ matrix " ‘of the root-sheath, is externally in relation with the outer 
root-sheath or prickle-layer of the hair-follicle. The protoplasm o 
the cells of which it is constituted contains kerato-hyalin in varying 
quantities, the amount being naturally greater in the cells lying nearest 
the hair-filament. That part of the sheath formerly termed ‘ ‘ Heule s 
layer '’ is the more externally situated cellular envelope of this in¬ 
ternal root-sheath, and is most conspicuous in that part of the hair- 
sac above the level of the papilla. That part of the sheath formerly 
called “ Huxley's layer" is the more internally situated part of the 
same sheath, somewhat higher in the follicle. Both these terms are 
now falling into desuetude as not being actually descriptive of distinctly 
different structures, but only of one structure in different situations. 
This structure, whether it is termed the internal root-sheath, or the 
matrix of the root-sheath, springs from the neck of the papilla, and 
rises as high as the neck of the follicle. It contains kerato-hyalin, 
which is actively concerned in the cornification of the hair-tissue. 

Between this internal root-sheath and the cells constituting the cor¬ 
tex of the hair there is found, according to Unna, the common matrix 
of the cuticuloe, forming respectively the cuticle of the root-sheath and 
the cuticle of the hair. The former is composed of cells with their 
long axes parallel with the circumference of the hair, while those 
forming the cuticle of the hair are arranged perpendicularly to the sur¬ 
face. These cuticulse are securely locked together by projection of 
their cell-edges, while united in the hair-follicle. 

The Bulb, or Root, is that portion of the hair imbedded in the 
skin, toward which the shaft of the hair gradually increases in 
thickness as it descends. The bulb is embraced by the hair-follicle, 
though its root-sheaths are interposed and implanted below at the base 
of the sac upon a nipple-shaped prolongation of the corium that may 
be regarded as analogous to the vascular papillai of the papillary layer 
of the corium. 

The bulb of the hair embraces the papilla, and is constituted of pig¬ 
mented cells externally, forming what is called the u cortex" or cor¬ 
tical portion. This is the larger of the two structures of which the 
hair is composed, and its cells become vertically elongated and narrow 
as they are pushed outward in the process of growth. 

The innermost structure of the hair is called its “ medulla," a tissue 
composed of non-pigmented, horizontally broadened cells containing 
kerato-hyalin. It rests directly upon the apex of the papilla below, 
and passes thence through the centre of the shaft of the hair like a 
delicate cylindrical core. Air-spaces occur between its epithelial cells 
as it rises toward the funnel-shaped opening of the hair-sac, but air 
does not enter the body of the individual cells. 

The Shaft of the Hair is that portion which extends from 
the exit of the hair at the surface of the skin to its extremity; the 
latter, when uncut, always tapers to a perfectly acuminate point, as 
illustrated by the uncut hairs of the eyelids, and those of the lower 


ANATOMY AND PHYSIOLOGY OF THE SKIN. 


39 


animals. I he hair-shaft is either straight, curled, wavy, or alternately 
varied in diameter, producing the peculiar character of the growth 
seen upon the scalp of the negro, these va¬ 
riations being due to the different degrees Fig 14 

of flattening of the hair-shaft in a trans¬ 
verse direction. 

The color of the hair is dependent upon 
the pigment it contains, the proper color of 
the hair-cells, and the quantity of air con¬ 
tained in the medulla. Variation in these 
three factors produces the wide range be¬ 
tween a snowy whiteness and an ebony- 
black. 

The membrane which invests the shaft 
of the hair is the cuticle composed of nu¬ 
merous flattened plates, regularly overlaid 
so as to resemble fisli-scales when viewed 
under the microscope on the flat side, and 
the overlapping shiugles of the roof of a 
house when seen on the edge. 



Transverse section ot hair and 
follicle. 


The Cortical, or main, Substance of the Shaft of the hair 
is composed of flat, nucleated, fusiform, epidermal cells. The strength, 
elasticity, and extensibility of the hair are chiefly due to the cortical 
substance, and in particular to the firmness with which these epidermal 
cells are attached to one another. 


The Medullary Substance of the Shaft of the hair is found 
best developed in the short, strong hairs of the beard and eyelashes, 
being wanting in the lanugo hairs. It consists of a loosely packed 
mass of epidermal elements, differing in shape, developed in the centre 
of the axis of the shaft. This part of the hair contains also the pig¬ 
ment and fatty matters, which are here arranged as in the rete of the 
epidermis. Seen under the microscope, the medulja appears as a con¬ 
tinuous or interrupted longitudinal band, extending from the bulb, 
or the part implanted in the follicle, to the extremity, or point of the 
hair. The purpose of this difference in the constitution of the cortex 
and medulla of the hair is doubtless to insure, on well-known mechan¬ 
ical principles, a maximum of strength, extensibility, and elasticity, 
with a minimum of volume. 

The coloring-matter of the hair is stored in both its horny and medul¬ 
lary portions, and is distinct both within and between the epithelial 
elements of which the hair is composed. This pigmentation corre¬ 
sponds, as Heitzmann has shown, in great part with the amount of 
pigment distributed to other parts of the integument, and sustains a 
close relation to the general nutrition of the body. Its subjection to 
the influence of the trophic nerves is well demonstrated by the phe¬ 
nomena of rapid blanching of the hairs. Excessive sweating whether 
physiological or induced by the action of pilocarpm, has also a dis¬ 
tinct influence upon the shade of color of the hair. 



40 


DISEASES OF THE SKIN. 


On transverse section hairs present an ovoid or ellipsoidal outline, 
suggesting an irregularly compressed circle. The degree of this flat¬ 
tening differs in different races, and is the cause of variability with 
respect to straightness or curliness. As hairs are to a marked degree 
hygroscopic, and not only absorb but can be deprived of a portion of 
their water, these states of waviness are subject to variation according 
to the aqueous condition of the media by which an individual is sur¬ 
rounded. 

Hairs differ from nails not only in their anatomical features, but 
particularly as to their physiological reproduction. Hairs are period¬ 
ically cast off and replaced by new filaments; the nails are shed and 
re-formed only in disease, in health they enjoy a continuous growth 
during the life of the body. 

When a hair is about to be shed it separates from its papilla in the 
hair-follicle and rises in the latter till it reaches above the level of the 
papillary apex. It is for a time held in place with sufficient firmness 
by the prickle-layer only, thus forming the bed-hair already described. 

Later an epithelial bud is projected either into the vacant follicle 
below or into the corium on either side, from which a new hair is 
formed, somewhat as the hair is formed in the primitive cone of foetal 
life. Later the growth outward of the new papillary hair pushes the 
bed-hair from its connection with the prickle-layer, and is shed. 


Sebaceous Glands. 

The sebaceous glands are pyriform bodies, usually racemose in devel¬ 
opment, situated in the corium, never in the subcutaneous tissue; they 
furnish a more or less consistent and fatty secretion destined to anoint 
the skin and hairs. They can usually be distinguished as of three 
classes, though only two of these classes include glands which are asso¬ 
ciated with hairs in the embryo. 

The first class, as proposed by Sappey, includes the sebaceous glands, 
which, strictly speaking, are appendages of the hairs and hair-follicles. 
They are developed early in foetal life from minute, lateral, bud-like 
prolongations from the outer root-sheath of the hair. From two to 
six of these prolongations spring from the prickle-layer of the hair- 
follicle; and the prickle-cells in the axis of each bud speedily undergo 
fatty metamorphosis. In the mature gland each acinus is formed of a 
membrana propria, on which are ranged layers of nucleated cuboidal 
epithelia undergoing fatty metamorphosis. Gradually the fattv cells are 
pushed outward toward the duct of the gland, where, sooner or later, 
their rupture releases numerous drops of fat just where the hair emerges 
from the closely applied follicle below to the funnel-shaped mouth of 
the hair-pouch above. Externally, each gland is provided with a layer 
of connective tissue. On account of the clearly defined relations of 
these bodies Unna would call them the “ glands of the hair-follicles.” 
They are found in connection with the long and soft hairs, as those of 
the scalp and the axillae, several being grouped around a single hair-sac. 

The second class includes the large and complex glandular structures 


ANATOMY AND PHYSIOLOGY OF THE SKIN. 


41 


to which the lanugo, or rudimentary hairs, seem accessory, the orifices 
of their respective ducts opening directly upon the cutaneous surface. 
These glands are chiefly found upon the so-called u non-hairy" por¬ 
tions of the skin, as upon the face in both sexes, and upon portions of 
the trunk and extremities. 


Fig. 15. 



Sebaceous glands of the second class from the alse of the nose. (After Sappey.) 


The third class, much the smaller number, includes those sebaceous 
glands opening directly upon the surface and unconnected with hairs or 
hair-follicles. Such are the glandulse odoriferse of the male and female 
genitalia (glands of Tyson), the Meibomian glands, and those existing 
about the lips and in the areola of the nipple.. These glands might 
be designated as the “ glands of the mucous orifices." 

The sebaceous secretion contains, chemically, water, palmitic and 
oleic acids, palmitin and olein soaps, and the saline constituents of the 
other organic animal compounds, chlorides and phosphates of the alka¬ 
lies and earths. The extrusion of the secreted sebum from the ducts 
of these glands is greatly favored by the action of the arrectores pilo- 
rum muscles, by whose contractions the gland is to a degree compressed. 
This is the reverse of what occurs in the coil-glands, whose secretion 
is impeded by the action of these same muscles. 







42 


DISEASES OF THE SKIN. 


Coil-glands. 

The Coil-glands, termed also Sweat or Sudoriparous glands, 
are globular coils situated in the subcutaneous tissue and in the deeper 
portions of the corium. They appear first in the fifth month of foetal 
life as buds projected downward from the prickle-layer of the epider¬ 
mis. Unna demonstrated that these projections always form between 
the papillae of the corium, and spring from the prolongations of the 
rete between these papillae. Long, thin cones of epithelium thus grad¬ 
ually traverse the corium, and become slightly bulbous at the lower 
extremity to form later the coil. The lumen, when formed, extends 
rapidly to the epidermis, and after this is reached there is made from 
within outward an opening, which becomes the sweat-pore. 


Fig. 17. 



Coil of the sweat-gland: S, tubule lined by cuboidal epithelia; T, central calibre of the tubule; 
D, beginning of the duct; C, connective tissue with injected blood-vessels. Magnified 500 diam¬ 
eters. (After Heitzmann.) 

These glands after birth are found in all parts of the body, but in 
certain regions, such as the axillae, the groins, the palms, the soles, 
and about the anus, they are either numerous, of unusual size, or pecu¬ 
liarly arranged. They are specially numerous in the palms and soles, 
where, according to Krause, there are between two and three thousand 
to the square inch. 

The coil is a convoluted tube terminating in a caecal pouch, lined 
with cubical epithelia of granular appearance, which are the secretorv 
cells of the gland. Outside of the tube are muscular fibres running 
parallel with or in a spiral direction about the coil. Surrounding both 
muscle-bundles and epithelium is a connective-tissue membrane. The 
glomerulus, or coil, is globular in outline and reddish-yellow in color 
In the larger glands irregular dilatations and constrictions of the tube 
are conspicuous. 





ANATOMY AND PHYSIOLOGY OF THE SKIN. 


43 


The excretory duct of the coil-gland passes from the glomerulus 
below to the epidermis above, in a straight or a spiral course. It is 
lined with a delicate hyaline cuticle (discovered by Heynold), beneath 
which is a double layer of cuboidal epithelium. Externally is a mem- 
brana propria, unprovided with muscular fibres. Its outermost sheath 
is the usual connective-tissue layer. When the duct reaches the border¬ 
line of the epidermis its inner cuticle and external connective-tissue 
sheath are both lost; here it becomes the sweat-pore. 



Fig. 18. 


The sweat-pore traversing the epithelial layers of the skin: BP, papilla with injected blood¬ 
vessels ; V, valley between two papillae; D, duct in the rete mucosum; E, E, epidermal layer; 
PL, coarsely granular epithelia, deeply stained with carmine; P, duct with corkscrew-windings 
in the epidermal layer. Magnified 200 diameters. (After Heitzmann.) 


The Sweat-pore is a continuation of the excretory duct of the 
coil-gland after the loss of its cuticle and connective-tissue sheath. It 
is the loss of these sheaths and the consequent intimate relation of the 
canal to the epithelia of the epidermis that furnish the special basis for 
this distinction. The sweat-pore is merely a wall-less canal or chan¬ 
nel, spirally directed or running a straight course from the duct of the 
coil-gland below to the outermost stratum of the epidermis above. It 
has no other wall than that formed by the cells of the prickle-layer 
below and of the other layers of the epidermis, which successively 
surround this canal, narrow below and funnel-shaped above. Hence 
the lumen of the sweat-pore, if such a term be permissible, is in free 
communication with the juice-spaces of the epidermis. 

The secretion of the coil-glands consists largely of globules of tat 
and granules of pigment. The function of the coil-glands, therefore, 
is plainly the lubrication of the skin with unguent a task performed 
only in small part by the sebaceous glands, and by them chiefly for the 
pilary covering of the body. The palms of the hands and the soles 
of the feet are thus lubricated with fat by the coil-glands. 

The total number of coil-glands in the body is estimated to be 






44 


DISEASES OF THE SKIN. 


between two and three millions, and the total length of the uncoiled 
glands about eight miles. These figures serve to give an approximate 
idea of their very great physiological importance, and of the extent 


Fig. 19. 



Section of skin from the palm of the hand (hardened in Moeller’s fluid and treated -with glacial 
acetic acid), magnified 300 diameters, showing epidermis and pars papillaris of the corium tra¬ 
versed by the excretory duct of a coil-gland terminating in a sweat-pore : a, stratum corneum ; 
a , its superficial layer, the cells in the upper and lower layers somewhat larger than those situ¬ 
ated between the two; b, stratum lucidum ; c, stratum granulosum ; d, stratum mucosum ; e, rete 
pegs ; /, interpapillary process of rete meeting duct of coil-glands ; g,g, papillae embraced by long 
prickles extending from lower palisade-iayer of the rete; h, blood-vessels of papillae ; i, bundles 
of connective-tissue fibres of pars papillaris; k, section of spiral duct of coil-gland and sweat-pore. 








ANATOMY AND PHYSIOLOGY OF THE SKIN. 


45 


to which violation of the rules of hygiene possesses interest from a 
pathological point of view. 

The function of the sweat-pores, which communicate directly with 
the excretory duct of the coil-glands, is distinct from that of the coil- 
glands, since it provides for the transmission outward of the watery 
fluids of the skin. The channel described as the sweat-pore is in ample 
and free communication with the intercellular spaces of the epidermis; 
and this anatomical peculiarity provides fully for all the needs of evap¬ 
oration at the surface of the body. 

The sweat excreted by the body differs under varying conditions of 
temperature, humidity of the air, and the amount and character of 
the articles ingested by the individual, either as food, drink, or medic¬ 
ament. Nearly 98 per cent, of the secretion is pure water, the remain¬ 
ing proportions representing the saline constituents of the other fluids 
furnished by the animal in life. In all chemical analyses of the sweat 
a source of error lies in the difficulty of securing the fluid secretion 
unmingled with that produced by the sebaceous glands; and the same, 
it may be said in passing, is true of the chemical analysis of the 
sebum. According to Duhring, the iodid of potassium, benzoin, and 
succinic and tartaric acids may be excreted with the perspiration. 

Unna, following in the lines indicated by Meissner, asserts that the 
coil-glands actually produce the subcutaneous fat-cushion; and the 
anatomical basis of such a statement is clear. The coil-glands and 
the fat-cushion appear at the same period of foetal life and develop in 
the same proportions. At birth the clusters of fat are most conspicu¬ 
ous where the coil-glands are most numerous. In the adult the greater 
number of coil-glands are subcutaneous in situation and are closely 
surrounded by fat-tissue; while those glands which do not descend 
below the corium, though not thus surrounded, are regularly met by 
columus of fat advancing toward them from below. 

The credit of discovering and naming these fat-columns belongs to 
Warren, whose studies were principally directed to the anatomy of the 
thick cutis vera. 1 The back and shoulders of a vigorous adult furnish 
an integument much thicker than the hide of many pachydermatous 
animals. The papilla? are imperfectly formed, and are represented by 
an undulating line. The follicles of the lanugo hairs penetrate only 
the superficial layers of the cutis. From the bases of the hair-follicles 
nearly vertical clefts, or slender, columnar-shaped spaces, extend 
obliquely to the panniculus adiposus, that were fitly termed by War¬ 
ren “ fat-columns ” or “ fat-canals/’ as they are entirely occupied by 
adipose tissue. (See Figs. 3 and 4.) 

These columns are 4 millimetres in length, and are. slightly wider 
than the hair-follicles above. The long axes form a slight angle with 
that of the follicle, but they are nearly parallel with that of the erector 
pili muscle. Two horizontal prolongations are given off on either side 
of the middle of this axis, partly fat-filled. Near this point Warren 
called attention to f ^the coil of a sweat-gland, held in place by a few 
delicate fibres.” The duct of the glaud runs to the top of this space, 

i Satterthwaite’s Manual of Histology, p. 420. New York, 1881. 


46 


DISEASES OF THE SKIN. 


whence it may be traced to the side of the hair-follicle. The connec¬ 
tive-tissue fibres seem to terminate abruptly at the edges of these col¬ 
umns. The cleft slightly widens below, and on the side toward which 
its axis leans the fibres of connective tissue form a bundle penetrating 
below to the subcutaneous fat. The erector pili muscle is inserted 
partly into the base of the follicle and partly into the apex of the fat- 
canal. 

These columns correspond in number with that of the hairs. The 
blood-vessels they contain, which spring from the subcutaneous plexus, 
bifurcate at the lateral clefts. 

The later studies of Unna demonstrate very clearly that the fat- 
columns, first recognized by Warren, invariably advance toward the 
coil-glands, the latter either singly or in groups, and that the connec¬ 
tion of the fat-columns with the hair-follicles is a mere incident of 
that advance. 

Fig. 20. 



Thin section of the skin of the finger removed at the site of a sweat-pore. Magnified 150 diam¬ 
eters. The cavities or spaces seen in the epidermis are, some, apparently uncolored ; others are 
blackened by the action of osmic acid upon fat originally contained in either cells or spaces 
between the latter. The effect is due to excretion of fat by the coil-glands, and the condition shown 
is not exhibited in all sections of the skin made at the same level. It is probably transitory and 
most apparent when the skin is macerated by sweat. 


The alternatiou of muscular fibres with the secretory cells of the 
duct of the coil-glands is a provision for the extrusion of the gland- 
secretion onward. The same anatomical arrangement permits free 
communication between the epithelia and the lymph-spaces which reach 
into the connective-tissue sheath of the gland/ As a result, the lymph 
flows freely among the secreting elements of the gland and its duct, 
this lymph, loaded with fat, streams away from the coils, and before it 
reaches the lymphatic truuks its fat-globules are filtered away in the 
subcutaneous tissue. 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 


47 


The Odorous Emanations from the Skin. 

The skin of the human body in health is the constant source of 
odorous emanations, which, in pathological conditions, may greatly be 
increased or otherwise changed. The nature and exact sources of these 
emanations are as yet imperfectly understood. Were they exclusively 
of a volatile, gaseous, or vaporous composition, even though such fluids 
were capable of condensation upon external bodies, it could scarcely 
explain the well-known fact that some of the lower auimals are capable 
of tracing the track of the human being for miles over a wind-swept 
path, until the soil pressed by the foot is covered with water. There 
is strong reason to believe that these emanations are vehicles by which 
certain contagious and infectious diseases are communicated from one 
individual to another. They at times contain living matter derived 
from the protoplasm of the body, and are capable of conveying bac¬ 
teria in compact masses and enormous quantities through the atmos¬ 
phere when agitated by a current of air. Some of the schizomycetes 
weigh but one-ten-billionth of a milligramme, and are transported 
through space in the most attenuated of media. These emanations are 
properly regarded as having their origin in the secreting system of the 
skin, but in what proportion the several secreting glands participate in 
their product it is difficult to establish. The sweat at times, even to 
human nostrils, exhales a distinct odor, though, as before indicated, to 
what extent this is due to the admixture of sweat with sebaceous 
material it is difficult to determine. Peculiarly fetid and disgusting 
odors occasionally originate in chemically altered sebum, where the 
influence of the sweat-secretion must be, from the locality under exam¬ 
ination, partly eliminated. 


Nails. 

Nails are dense, elastic, and translucent conravo-convex plates, or 
shells of horny tissue, placed upon the dorsum of the terminal extrem¬ 
ities of the distal phalanges of the fingers and toes. Each nail has a 
free border at the distal portion of the pulp of the digit, with sides 
and proximal borders let into distinct furrows of the skin. The con¬ 
vex surface of the nail is exposed, the concave regarding the phalanx, 
and is implanted upon the nail-bed beneath. 

In the embryo the first change looking to the future formation of 
a nail consists in a peculiar smoothness and brilliancy of the epidermis 
covering the dorsum of the distal phalanges. Later, an epithelial 
ridge or line with a groove in front of it traverses the tip of the finger. 
Thus, three regions are defined: the region behind the ridge, the nail- 
wall; that in the groove, the nail-bed; and that in front of the groove, 
the pulp of the last phalanx of the digit. A collection of large prickle- 
cells at the orifice of the nail-fold soon furnishes the first trace of the 
rudimentary nail. Mature nail-cells finally push forward between the 
prickle and horny layers of the nail-bed, which, by fan-shaped bundles 
of follicles, is firmly united to the periosteum of the phalanx. Lastly, 


48 


DISEASES OF THE SKIN. 


a thin plate of homy material with a free edge is visible externally in 
the fingers and toes of the newborn child. 

Fig. 21. 



Vertical section of one-half of nail and matrix : a, nail-substance ; 6, horny layer ; c, mucous 
layer ; d, papillae of corium ; e, nail-furrow destitute of papillae; /, horny layer of the ungual 
furrow rising above the nail; g, papillae of skin of dorsal surface of the finger. 

In the adult, what is termed the matrix of the nail is the tissue 
from which springs the horny plate. The matrix is separated, as 
shown by Hans Hebra, into, first, a posterior part, filled with from 
three to six rows of papillae, and next, in advance of this, is a lentic¬ 
ular space with curved borders, the anterior limit of which corresponds 
with the anterior border of the lunula. The area included in these two 
divisions is provided with papillae grouped in symmetrically converg¬ 
ing ridges, decreasing in size as they pass forward. This forms the 
matrix of the nail. Further forward, the nail-bed proper—in other 
words, the tissue that supports, rather than produces the horny plate— 
is composed of higher ridges of papillae whose grooves and summits 
are covered with prickle-cells, and whose height is uniformly main¬ 
tained as they stretch forward toward the pulp of the finger. 

The Nail, or, as termed by Unna, the true nail, or nail-plate, orig¬ 
inates only from the floor of the nail-fold as far forward as the anterior 
edge of the lunula. As to its formation, it may, therefore, be imag¬ 
ined as springing from its matrix vertically in the form of an involuted, 
shield-shaped plate, its convexity regarding the proximal phalanx. It 
may then be viewed as pressed downward over its nail-bed in front, 
with partially unfolded edges enwrapped by the epidermis of the sides, 
the narrowed point of the shield, elongated when untrimmed, project¬ 
ing at some distance beyond the tip of the finger. 

With this conception it is easy to understand that the nail is consti¬ 
tuted of horny filaments, or coherent strata of cornified cells, passing 
from the matrix or floor of the nail-fold. The upper surface of the 
nail grows, therefore, from the bottom of the nail-fold; the under 
surface from the lunula; and the intermediate layers proportionately 
from the parts between, that interlock with corresponding grooves on 
the upper face of the bed. 


ANATOMY AND PHYSIOLOGY OF THE SKIN 49 

The Nail-fold, crescentic in shape, clasps the nail posteriorly and 
laterally. It is formed of connective tissue, whose bundles are inter¬ 
penetrated by numerous coil-glands and fat-columns. The epidermis 
beneath the nail exhibits priclde, granular, and horny layers. As the 
nail is gradually liberated from its bed both at the sides and point, the 
cornification of the horny layer becomes more complete, so that finally, 
as the nail-plate is pushed forward, it no longer rides over the cells of 
the rete, but over a completely cornified tissue. 


Fig. 22. 



Implantation of the nail at its border: P, papillae decreasing in size toward the middle line; 
R, rete mucosum, which broadens toward the border of the nail, and forms irregular prolonga¬ 
tions; R', E, epidermal layer; N, plate of the nail. Magnified 500 diameters. (After Heitzmann.) 


If the pulp of any nail-bearing phalanx be pressed with moderate 
force against any firm object, the naked eye can detect upon the surface 
of the nail, just behind its free border, a yellowish-white band, convex 
anteriorly and somewhat increasing in width laterally.. Phis line is 
also visible when no pressure is exerted upon the digit, its width vary¬ 
ing under the conditions described. This border represents the space 
in which the three layers of the epidermis from the skin of the point 
of the finger, viz., the horny, the granular, and the prickle-layer, suc¬ 
cessively come in contact with the under surface of the nail. 

The lunula is the relatively light-colored space extending from the 
middle part of the nail-fold posteriorly to its well-defined convex 
border in front. After artificial removal of the nail-fold the lunula 
is seen to extend to the posterior and enclosed border of the nail-plate. 
It therefore, represents that part of the matrix of the nail not con¬ 
cealed by the nail-fold. Its color is not due to absence of vascularity, 
but is solely due to opacity of the keratogenous cells (Ranvier) which 
are concerned in the production of the horny threads that form the 
nail. 


4 



















50 


DISEASES OF THE SKIN. 


II. GENERAL SYMPTOMATOLOGY. 


In cutaneous, as in other diseases, the clinical signs or symptoms 
of the morbid process are those by which the disease is recognized 
alike by the patient and the physician. These signs and symptoms are 
divided into subjective and objective: the former are those appreciated 
by the patient alone in consequence of his sensations; the latter are 
those detected by the eye and the touch of another who undertakes the 
investigation of the disease. It should be remembered, however—and 
this is a matter of some importance in this connection—that there are 
manifested to the eye and touch of the patient many objective signs 
which are liable to be interpreted or misinterpreted by him, with 
consequences not to be ignored. 

Subjective Symptoms. The purely subjective symptoms of a dis¬ 
ease of the skin are those manifested to the patient by sensations other 
than those connected with vision and his own sense of touch. They 
include sensations of itchiug, smarting, tingling, pricking, and burn¬ 
ing; sensations as of increased or diminished susceptibility to the con¬ 
tact of foreigu bodies; of increased or diminished temperature; pain 
in various grades of severity; and disordered sensations, such as the 
crawling of insects over the part, the passing of currents of hot or 
cold vapors or liquids, and the compression of portions of the skin as 
by either cords, bands, or closely fitting plates. The character of the 
subjective sensations experienced by a patient often proves an aid to 
the physician in recognizing the nature, not merely of a present disease, 
but also of one which has preceded. Thus, the sensation produced 
by an attack of erysipelas is rarely an itching, while the latter is 
highly characteristic of eczema and scabies; the pain of zoster and the 
tingling of urticaria being distinctly different, not only from each other, 
but also from the subjective symptoms named above. 

Objective Symptoms. The study of the objective symptoms of 
a cutaneous disease is of paramount importance. In no respect does 
the skilled physician so distinguish himself from one who is unskilled 
as in ability to recognize the typical or atypical objective characters 
presented in diseases of the skin. This study is one which no diag¬ 
nostician can safely neglect, and its rewards are precious in every 
departmeut of medical science. These symptoms are spread before 
the eye, and their legibility increases with every hour of careful obser¬ 
vation. 

These signs of skin disease—or, more literally, skin injury—are 
called “ lesions/’ and it is usual to classify them as primary and sec¬ 
ondary. Such division, however, is open to criticism, since, in point 
of time merely, some of the so-called “ primary lesions” of the skin 
become in turn secondary and even tertiary. Thus, a papule which 


GENERAL S YMPTOMA TOL OGY. 


51 


might at one time be. called “ primary,” may be transformed wholly 
or in part into a vesicle, which thus becomes a secondary lesion, and 
such vesicle again, in the evolution of a disease, may become a tertiary 
pustule, and the latter finally may result in a quaternary crust. In 
the following pages these symptoms of skin disease are distinguished 
as elementary and consecutive. 


Elementary Lesions. 

In describing the average size of cutaneous lesions it is less con¬ 
venient to state their measurement in fractions of a line or of a milli¬ 
metre than to convey an approximate idea by a comparison with familiar 
objects of relatively fixed dimensions. The objects usually selected for 
this purpose, beginning with the smallest, are seeds of the poppy, mus¬ 
tard, and rape; the coffee-bean; the pea; the bean; the cherry; the 
finger-nail; the chestnut; the horse-chestnut; the egg of the hen 
and of the goose; the orange. To these may also be added the point 
and head of a pin. The student will find it useful to familiarize him¬ 
self with the size of the small seeds mentioned, that their names may 
at once suggest to him the relative size of the lesions with which they 
are compared. 

Macula (spots, or stains) are generally circumscribed 

ALTERATIONS IN THE COLOR OF THE INTEGUMENT, DIFFERING AS 
TO SIZE, SHAPE, HUE, AND DURATION OF THE DYSCHROMIA, AND 
UNACCOMPANIED BY ELEVATION OR DEPRESSION OF THE SKIN SUR¬ 
FACE. 

Maculae may be due to arterial or venous hypersemia, to the escape 
of the coloring-matters of the blood into the skin, to acquired and 
congenital telangiectases, and to pigment-anomalies. Examples of mac¬ 
ulae are to be found in the exanthematous rashes (measles); in localized 
hyperaemia of the capillary plexus of the corium, disappearing in vari¬ 
ous degrees according to the pressure exerted on the part (rosacea); in 
visible acquired development of blood-vessels in the skin (telangiec¬ 
tasis) ; in congenital vascularization of the surface (naevi); in variously 
colored blood-extravasations and stases (purpura); in stains produced 
by contact with dyes (hand-workers in anilin); and in pigmentary 
changes such as those produced by solar heat (freckles), or by leprosy. 

Extensive non-circumscribed changes in the skin-color are seen in 
the course of several general disturbances of the economy, as in yellow 
fever, cancer, chlorosis, albinism, Addison’s disease, argyria, and 
icterus. 

Spots of various color and device are also produced by the inten¬ 
tional or accidental introduction of pigmented particles beneath the 
epidermis, as by the process of tattooing, the explosion of gunpowder, 
etc. 

Maculse exhibit a wide variation in color from a rosy-pink to a choco¬ 
late-brown or even a black. This difference has suggested the employ¬ 
ment of such descriptive terms as roseola, erythema, and purpura, 


52 


DISEASES OF THE SKIN. 


which, unfortunately, serve to distinguish both the features of diseases 
and the diseases themselves. 

A macula which encircles another lesion, as, for example, the halo 
around the vaccine-vesicle, is called an “areola.” Linear hemor¬ 
rhagic streaks are called u vibices;” punctate and larger extravasations 
of blood are termed “ petechise” and “ ecchymoses.” 

Papulae (or papules) are solid or compressible, ephem¬ 
eral OR persistent, circumscribed projections from the sur¬ 
face OF THE SKIN, VARYING IN SIZE FROM THAT OF A POPPY-SEED 
TO THAT OF A COFFEE-BEAN. 

These exceedingly common skin-symptoms vary greatly in their 
shape, color, location, career, and significance. Thus, they may be 
flattened at the apex, acuminate or pointed, conical, rounded, or de¬ 
pressed at the summit to form an umbilication; they may be pale, rosy, 
dark- or lurid-red, purplish, or even blackish; they may develop in 
transitory or persistent processes; they may be transformed into lesions 
containing fluids; may desiccate and furnish scales either at apex or 
base; may degenerate into ulcers; or may enlarge into tubercles or 
tumors; may be scratched, torn, or rubbed so as to lose their typical 
appearance; may come and go; may be sensitive to sudden changes in 
the blood-current, and yet be persistent. 

The mixed forms described above are generally named vesico-papular 
or papulo-vesicular, papulo-squamous, papulo-pustular lesions, etc. 

Lesions which simulate the papule and which, though described 
under that title, really belong to another category, are the small, semi¬ 
solid elevations of the surface that form at the orifices of the ducts of 
the cutaneous glands and follicles. Thus they may consist of little 
heaps of epidermis about the hair-follicles (lichen pilaris, keratosis 
pilaris), or of inspissated sebum collected in one of or in all the acini 
of the sebaceous glands (milium, comedo). 

The concomitants of an eruption of papular type also vary. Thus 
there may be a febrile process, or extensive infiltration of the skin 
about and beneath the papules (prurigo), or itching of the most in¬ 
tolerable character (eczema papulosum), or production of trifling sen¬ 
sations of annoyance, as a slight burning without other subjective 
symptoms (acne, lichen planus). 

Papules transformed into moist lesions become covered with a crust. 
Papules scratched or torn by the finger-nails usually betray the fact in 
the. minute and flat blood-scale dried upon their surface. Papules 
which ulcerate may be followed by scars, and those which have under¬ 
gone the process of involution may be followed by macular sequel*. 

POMPHI (URTICiE, OR WHEALS) ARE MORE OR LESS TRANSITORY, 
ROSY-RED AND WHITISH, IRREGULARLY SHAPED AND SIZED ELEVA¬ 
TIONS OF THE SURFACE OF THE SKIN, PRODUCED BY BLOOD-STASIS IN 
SPASM OF THE VESSELS, ACCOMPANIED BY A TINGLING OR A PRICKLING 
SENSATION, AND CHARACTERIZED BY RAPIDITY OF EVOLUTION AND 
FREQUENCY OF RECURRENCE. 

The typical wheal is seen in the disease known as u nettle-rash” 


GENERA L 8 YMF TOMA TOL 0 G Y. 


58 


(urticaria), in which closely packed, shining, roundish and whitish, 
pea to finger-nail-sized elevations of the skin are visible, surrounded by 
a slightly rosy border. Wheals are firm to the touch, and arranged in 
patches, circles, bands, gyrations, or striations, often disappearing in a 
brief time and recurring with or without a renewal of the cause. They 
are occasioned by a rapid exudation of serum into the rete or pars papil¬ 
laris of the coriurn. This is supposed to be due to clonic vascular 
spasm, producing irregularities in the lumen of the skin-capillaries, 
under the influences of the vaso-motor nerves which supply a small 
area of the superior pars vascularis of the derma. The sensations pro¬ 
duced by wheals are particularly stinging, burning, pricking, and 
itching. They are often surrounded by an areola 

u Giant” wheals are such as enlarge to the dimensions of a hen’s 
egg, or cover extensive areas of integument, as, for example, the entire 
surface of the buttock or the shoulder. 

Ilelics of disappeared wheals are usually transitory erythematous 
macula?, but in rare cases there is left a more or less deep pigmentation 
which slowly disappears (urticaria pigmentosa). 

It should be borne in mind that at times the wheal-like condition is 
assumed by papillae, as also by lesions resulting from such traumatism 
as the bites of insects, reptiles, horses, dogs, etc. 

Tubercula (or tubercles) are circumscribed, solid, gen¬ 
erally INCOMPRESSIBLE AND PERSISTENT, NODOSITIES OF THE 
SKIN, VARYING IN SIZE FROM THAT OF A COFFEE-BEAN TO THAT OF 
A CHERRY. 

Tubercles may largely be projected from the free surface of the integ¬ 
ument, or be deep seated in the skin, and but a small portion become 
evident to the view externally. Their varieties as to shape, color, size, 
and other features correspond in great part with those described in 
connection with papules. They may be attached by a broad base to 
the skin, or be pedunculated, or even pendulous. Their scat is usually 
in the deeper portions of the coriurn, or in the subcutaneous connective 
tissue. Degenerating and ulcerating tubercles are followed, as might 
be supposed in view of their volume, by considerable destruction of 
tissue, and correspondingly in cases of repair by extensive cicatrices. 
Tubercles are seen in such diseases as fibroma, molluscum epitheliale, 
syphilis, leprosy, sarcoma, and cancer. 

Tubercles arc often described as merely enlarged papules, but the 
distinction between these two forms of lesions will better be recognized 
when attention is paid to the particular portion of the skin in which 
each takes its origin. Papules spring oftenest from the superficial 
layers of the derma; tubercles from the deeper layers. This fact being 
remembered, it will be clear that at times a tubercle rnay project from 
the surface to a less extent than a papule, though its larger volume 
is evident as soon as the skin within which it has developed is 

handled. . 

Tubercles due to a cellular infiltration rnay cease to be circumscribed, 
and by coalescence furnish a diffuse involvement of both the skin and 
the subcutaneous tissue. 


54 


DISEASES OF THE SKIN. 


Phymata (tumores, or tumors) are masses of solid tissue, 

OR OF SOLID TISSUE MORE OR LESS COMMINGLED WITH FLUIDS OF 
VARIABLE CONSISTENCY, DIFFERING IN SIZE, SHAPE, COLOR, AND IN 
THE BENIGNITY OR MALIGNITY OF THEIR CAREER, LOCATED EITHER 
WITHIN OR BENEATH THE SKIN, OR BEING ATTACHED TO THE SKIN, 
PROJECTING FROM IT TO A VARIABLE EXTENT. 

The mere fact that a lesion of the skin approaches in dimensions the 
size of a tumor is in itself an element of gravity. Tumors may orig¬ 
inate in mere hyperplasia of the living matter; may consist of new 
formations of greater or lesser danger to the vicinage, or to the general 
economy; may be formed of blood- or of lymphatic vessels, or of both 
in the same lesion; may embody large fluid-containing cysts; may be 
built up of nerve-tissue, fat, bundles of connective-tissue fibres, gland¬ 
ular elements, and indeed of any of the elements which exist physio¬ 
logically in the human integument. 

Examples of tumors are seen in fibroma, sarcoma, carcinoma, and 
rhinoscleroma. 

Vesiculje (or vesicles) are elevations of the horny layer 
OF the epidermis with limpid, lactescent, or sanguinolent 

FLUID-CONTENTS, VARYING IN SIZE FROM THAT OF A POPPY-SEED TO 
THAT OF A COFFEE-BEAN. 

Typical vesicles are seen in the minute, transitory lesions occurring 
in the vesicular form of eczema. They are usually filled with a clear 
serum. Variations from this type, however, are common. Thus, they 
may be either flattened, acuminate, roundish, umbilicated, or conical; 
may be fully distended or partially collapsed upon their contents; may 
have a short or long duration; may be distended with a milky, chylous, 
or blood-stained fluid; may be opalescent, yellowish, reddish, or 
blackish in color; several may coalesce to form a many-cliambered 
lesion; one or several may undergo transformation into pustules or 
bullse. Vesicles may terminate by accidental or spontaneous rupture, 
their contents freely flowing forth upon the surface of the peripheral 
integument; or they may desiccate to a crust; or may even terminate 
by one of the ulcerative processes. They may or may not be accom¬ 
panied by pruritus. Minute vesicles, which are merely the external 
apices of large-chambered accumulations of fluid beneath, occasion* 
ally form upon the surface of the skin. Such are seen in the course 
of lymphangiectasis. 

PUSTULE (or PUSTULES) ARE CIRCUMSCRIBED CUTANEOUS AB¬ 
SCESSES, COVERED WITH AN EPIDERMAL ROOF-WALL, AND VARYING 
IN SIZE FROM THAT OF A MILLET-SEED TO THAT OF A FILBERT. 

The typical pustule contains pus, and is colored yellowish, yellow¬ 
ish-green, or brownish-green, according to the admixture of its contents 
with blood. The pus being an inflammatory product, necessarily indi¬ 
cates the occurrence, at the base of the pustule, of an inflammatory 
process. Pustules, like vesicles, may be roundish, acuminate, globoid, 
conical, 01 umbilicated, and surrounded by an inflamed or normal 


GENERAL SYMPTOM A TOL OGY. 


55 


integument; may be superficial or be deep-seated; may terminate by 
rupture or by desiccation; may or may not be followed by an ulcer 
and ultimate cicatrix. They may be seated either upon the free sur¬ 
face of the skin, or at an orifice of a follicle, in which case they rep¬ 
resent an inflammation with purulent product in the duct or the gland 
beneath. 

Pustules may originate as such, or as a consequence of transforma¬ 
tion of vesicles, or after a change in a papule, which may thus come 
to have a purulent apex. According to Auspitz, they invariably 
originate from vesicles. Pustules often result in the formation of 
crusts, the latter varying in color according as the pustules from which 
they originated contained a clear serum or blood. 

Transitional forms between vesicles and pustules are termed vesico- 
pustules. Pustules of a large size, resting upon an indurated, engorged, 
and elevated base are often called “ ecthymatous.” 

Pustules are seen in syphilis, variola, eczema, scabies, acne, and many 
other cutaneous diseases, including several forms of dermatitis medica¬ 
mentosa. They all contain pus-cocci. 

Bull.® (or blebs) are superficial or deep-seated eleva¬ 
tions OF THE SKIN HAVING FLUID-CONTENTS, DIFFERING IN COLOR, 
SHAPE, AND CAREER, AND VARYING IN SIZE FROM THAT OF A 
COFFEE-BEAN TO THAT OF A GOOSE-EGG. 

Blebs have been described as large vesicles; but this fails to define 
exactly their pathological character. Like vesicles they may contain 
serum, lymph, blood, or pus, and may variously be colored according 
to the degrees in which their contents become visible through a semi¬ 
transparent roof-wall. They may be globoid, hemispherical, oval, 
crescentic, semi-crescentic, or conical, and may even exhibit angles. 
They may be seated upon an apparently unaltered or an evidently 
morbid integument; and may or may not present a peripheral areola. 

Bullae may persist or may rupture; may desiccate or may degenerate 
into ulcers; may collapse after the escape of their contents, and the 
roof-wall become glued to the base from which it was originally raised. 
Bullae usually occur in extremely debilitated states of the system, and 
are, as a rule, of graver portent than other fluid-containing lesions of 
the skin. They occur in scalds and burns, in pemphigus, leprosy, 
erysipelas, syphilis, and moist gangrene. 


Consecutive Lesions. 

Squam® (or scales) are attached or exfoliated epithe¬ 
lial LAMELL®, WHICH HAVE BECOME APPRECIABLE AT THE SUR¬ 
FACE AS THE RESULT OF SOME MORBID PROCESS IN THE SKIN. 

There is constantly in progress over the superficies of the body physio¬ 
logical desquamation, the evidences of which are not pronounced in skins 
properly cleansed by ablution. In morbid processes, however, desqua¬ 
mation may occur as a distinct symptom in various forms. Thus, the 


56 


DISEASES OF THE SKIN. 


scales may be minute, fine, branny, dirty-white or yellowish; they may 
be large, pearly-white, shining; may be dry or fatty; may be aggre¬ 
gated so as to resemble flaky pie-crust; may exfoliate in extensive 
sheets, as from the entire sole of the foot or the palm of the hand, or 
in glove-finger-like sheaths, as from the surface of a digit; they may be 
scanty, scarcely perceptible, and so attached, as to require force or 
their removal; they may fall spontaneously in a pulverulent shower, 
being so abundant as to fill the garments or the bed-clothing of the 

patient. # . 

Furfuraceous desquamation is that form in which fine bran-like scales 
are shed from the surface. 

Scales are frequently intermingled with other lesions, often succeea- 
ing the latter. Thus, a papule may scale at its apex, or surround its 
base with a collarette of loosened epidermal plates, beneath or between 
which a macular stain is visible. Again, they may develop from 
macule, tubercle, or tumor. Though generally conceded to be evi¬ 
dences of a dry and non-discharging disease of the skin, they are at 
times accompanied or succeeded by moisture of the part affected. 

The term scales is sometimes applied to the flattened plates of dried 
sebum that form on the scalp and on portions of the trunk in sebor- 
rhoea sicca. 

Scales occur in eczema, psoriasis, pityriasis, ichthyosis, syphilis, and 
in several of the parasitic diseases of the skin. 

Crust^e (or crusts) are relics of the desiccation of the 

PATHOLOGICAL PRODUCTS OF THE SKIN. 

Crusts never occur as primary symptoms of disease. When formed 
by the desiccation of serum only they are of a yellowish, straw-yellow¬ 
ish, or reddish-yellow hue; when composed largely of dried pus they 
are colored greenish, or greenish-yellow; and, wheu there has been 
an admixture of blood, they are usually brownish or blackish. At 
times they suggest in appearance gum, honey, or Venice turpentine; 
in shape they may have the form of the concavo-convex lid of a watch- 
case; in color and shape they may resemble the half-shell of an oyster, 
or the carapace of a small turtle. They may be delicate and thin, 
bulky and thick, friable or mealy; may be firmly attached to the sub¬ 
jacent tissues, or readily separable; may cover a sound, though tender 
and reddened epidermis; may conceal a superficial, or a deep, foul- 
based ulcer, by secretions from beneath which they are raised above 
the plane of the skin and increased in thickness; they may be circum¬ 
scribed and no larger than a small finger-nail; may envelop an entire 
limb or organ, as the leg or the penis; or, finally, may be so irregu¬ 
larly disposed among other lesions, papules, pustules, excoriations, and 
open ulcers, that it is difficult to define their outline, and even to recog¬ 
nize their identity. Crusts formed of dried sebum are greasy to the 
touch, dirty-yellowish in shade, and usually seated upon a non-infil- 
trated base. 

Crusts are common in eczema, syphilis, leprosy, seborrhoea, and in 
a large number of other diseases of the integument. 


GENERAL SYMPTOMATOLOGY. 


57 


Excoriations are superficial solutions of continuity, 

USUALLY INVOLVING PORTIONS OF THE SKIN AFFECTED WITH 
PRURITUS, AND RESULTING FROM MECHANICAL VIOLENCE. 

Excoriations, in appearance amog the most trivial of skin lesions, 
possess a value from the diagnostic point of view which can scarcely be 
overestimated. They occur as striated, linear, punctate, circular, or 
irregularly shaped furrowed wounds, at times involving areas of flat 
surface, onzing with serum or blood, covered with dried blood or crusts, 
yellowish or reddish in hue, and for the most part both induced and 
accompanied by severe pruritus. They may coexist with hypersemia 
aud infiltration of the skin beneath, brought on by the irritative char¬ 
acter of the continuous, or, more frequently, interrupted cause by 
which they were begotten. 

Excoriations become significant according as they indicate scratch¬ 
ing, tearing, or other species of wounding by the finger-nails, and the 
rubbing of portions of the integument with foreign bodies. In the 
former case they are significautly recognized in those portions of the 
body most accessible to the hands, though in the case of eczematous 
children and infants they may originate by the rubbing together of the 
knees, or the rubbing of one leg by the feet and toes of the other leg. 
The loss of tissue may extend deeper than the rete—at times invading 
the papillae of the corium, which bleed in consequence. 

Excoriations may occur without the appearance of other lesions, as 
in the disease called “pruritus;” but where itching is severe and 
induced by a cutaneous exanthem the lesions constituting the latter 
may be intermingled with, obscured, or even obliterated by excoria¬ 
tions and the pathological processes to which they give origin. Thus, 
macules, vesicles, pustules, and papules may undergo change; and the 
recognition of the type of the existing disease may correspondingly be 
difficult. Excoriations are common in skins wounded by lice, bed¬ 
bugs, and gnats; in the subjects of eczema, scabies, intertrigo, and 
prurigo; and in individuals with special sensitiveness of the integument 
to the action of a medicament employed either internally or externally. 

Riiagades (or fissures) are linear solutions of continuity, 

USUALLY OCCURRING IN PREVIOUSLY INFILTRATED PORTIONS OF 
THE SKIN. 

Fissures may extend to the derma, and even invade yet deeper struc¬ 
tures; may be- painful, or the reverse; may be dry, secretory, or 
incrusted; are often hemorrhagic, and usually are formed with sharply 
cut walls. They are of frequent occurrence in the vicinity of the 
articulations, in which situations they are induced or aggravated by 
the joint-movements stretching or tearing tissues whose extensibility 
has been diminished by any morbid process. Fissures may terminate 
in ulceration; thev vary as to length, curve, and tenderness; they are 
often exquisitely painful, and greatly complicate the skin disease m 
which they form; they may follow the curve traced by the boundaries 
of bodily organs near which they occur—as, for example, the line of 
the posterior junction of the ear with the head, or that of the breast 
of a woman with the thoracic wall upon which it rests. 

Fissures occur in eczema, syphilis, dermatitis, and lichen ruber. 


58 


DISEASES OF THE SKIN. 


Ulcer a (or ulcers) are losses of substance resulting from 

A PREVIOUS PATHOLOGICAL PROCESS INVOLVING THE CORIUM, AND, 
IN SOME CASES, THE SUBCUTANEOUS TISSUE. 

Cutaneous ulcers differ greatly in size, shape, color, edges, base, 
career, and, indeed, in all their characteristics. Every ulcer has an 
outline, a base, a floor, edges, and a secretion. The outline may be 
circular, crescentic, reniform, ovoid, serpiginous, or with horseshoe¬ 
like contours. The base, or underlying tissue, may be soft, supple, 
indurated, or in a state of active inflammation, with consequent infil¬ 
tration. The floor may be glazed, shallow, deep, excavated, cup- or 
funnel-shaped, u worm-eaten/’ crateriform, sloughy, covered with a 
tenacious or a readily removed secretion, granular, puriform, or hem¬ 
orrhagic. The edges may be clean-cut, having a punched-out appear¬ 
ance, undermined, everted, ragged, irregular, or contracting, with a 
whitish inner border of advancing cicatrization. The secretion may 
be scanty, limpid, puriform, profuse, ichorous, and odorless, or exhale 
an offensive stench. Ulcers may be so crust-covered as to be invisible, 
or so exposed and erosive in action as to render the affected surface in 
the highest degree unsightly. They may be acute or chronic, insensi¬ 
tive or productive of intense pain; may heal by cicatrization, remain 
open for a lifetime, or prove fatal either by destruction of parts essen¬ 
tial to life, or by exhaustion of the vital forces. 

Cicatrices (or scars) are new-formed substitutes for lost 

CONNECTIVE TISSUE. 

Scars never succeed excoriations, fissures, or other solutions of con¬ 
tinuity in the skin, that have not penetrated as far as the derma and 
resulted in destruction of a portion of the elements of which the derma 
is built up. They possess the highest importance for the diagnostician, 
since they point invariably to a pathological process whose career is 
terminated, the characteristic features of which termination they fre¬ 
quently embody. They may be regarded as the special and persistent 
imprints upon the integument of the serious disorders from which it 
has suffered. 

To a certain extent, as already shown, scars retain traces of the spe¬ 
cial peculiarities of the lesions, and even of the diseases, which they 
succeed. The identification, however, of the individual predecessor 
in each instance is, in the present state of our knowledge, not always 
possible from a study of cicatrices alone. The extent of knowledge 
in this direction, however, is rapidly increasing; aud in many cases 
the certainty thus acquired is of incalculable value to the diagnos¬ 
tician. 

Scars are remarkable for their tendency to contraction and gradual 
decoloration. They may be minute, punctate, extensive in area, 
attached to underlying tissues, depressed, raised above the plane of the 
peripheral skin, seamed with furrows, pliable and soft, indurated, trav¬ 
ersed. by ridges, knotted, or as irregular in contour as the ulcers already 
described. They may extend in digital, linear, or annular prolonga¬ 
tions toward contiguous portions of the skin, and by subsequent con¬ 
traction induce considerable distortion and deformity. Thus, they 


GENERAL SYMPTOMA TOLOG Y. 


59 


may drag down an eyelid and ectropion ensue; may glue the lobe of 
the ear to the cheek; may evert lip or nostril. When recent, they are 
usually reddish in tint; when older, may be pigmented in centre or 
circumference; or, as is common, may exhibit a gradual decoloration, 
centrifugal in its progress. They may be the seat of pain from an 
entrapped nerve-filament; may reopen to ulceration; or may be unac¬ 
companied by subjective sensation. Not rarely they become the origin 
of the disease known as u cicatricial keloid .” Scars are unprovided 
with hairs, papillae, or the orifices of sweat-pores and sebaceous gland- 
ducts. As implied in the definition given above, scars may result from 
any disease or injury of the skin that involves loss of connective-tissue 
elements in the corium. 

To the several lesions defined above Bazin adds, as elementary forms, 
the mucous patch of syphilis, the cuniculus, or furrow, produced in 
the skin by the acarus scabiei, and the sulphur-colored crusts of favus. 
These, however, are not general, but special features of individual 
disorders, and are best studied in connection with the latter. 

The elementary lesions of the skin are termed by Auspitz, anthe- 
mata ; groups of such lesions, synanthemata ; and, in accordance with 
common usage, generalized eruptions affecting the entire surface of 
the body, exanthemata. The word erythanthema is used to describe 
groups composed of several of the elementary lesions of the skiD, as, 
for example, of papules, vesicles, and pustules rising from a common 
reddened and hypersemic base. 

In addition to the names of the lesions of the skin just enumerated, 
certain peculiarities of cutaneous symptoms are described in qualify¬ 
ing terms, which here require definition. They relate chiefly to 
the color, shape, distribution, and method or period of evolution of 
lesions as they are observed in individual cases. The more important 
of these terms, as used by modern writers, are alphabetically arranged 
below, with a brief explanation appended to each. A much larger 
list of obsolete adjectives, employed by older authors, is purposely 
omitted. 

Abdominalis. Located on the abdominal surface. 

Acquisitus. Acquired. 

Acuminatus. Having a pointed apex. 

Acutus. Of acute course. 

Adultorum. Occurring in adult years. 

AEstivalis. Occurring in the summer season. 

Aggregatus. Collected in patches. 

Agrius. Acute, or angry in appearance. 

Albidus. Of whitish color. 

Angiectaticus Vascularized. 

Annularis. 1 j f orm of a r i ng . 

Annulatus. / 

Apyreticus. Unaccompanied by fever. 

Areatus. Occurring in areas. 

Artificialis. Producible artificially. 

Asymmetrical^. Of different distribution on the two lateral halves of the body. 
Autumn a lis. Occurring in the autumn. 

Brachialis. Occurring on the surface of the arm. 


60 


DISEASES OF THE SKIN. 


Cachecticorum. Occurring in debilitated subjects. 

Capitis. Occurring on the head, usually the scalp. 

Cavernosus. Large chambered. 

Chronicus. Chronic in course. 

Circinatus. Of circular outline. 

Circumscriptus. Having a definite contour. 

Confluents } Arranged in close proximity, with coalescence of lesions. 

Contagiosus. Capable of communication by contagion. 

Corporis. Occurring on the surface of the body; employed usually to designate an 
eruption upon the trunk, as distinguished from that on the head or the extremities. 
Crustosus. Crusted. 

Crystallinus. Of crystalline appearance. 

Diffusus. Irregularly disposed. 

Discretus. Having isolated lesions. 

DrssEMiNATUS Disseminate,, without regularity of distribution. 

Eruption. Is used of the totality of all patches and lesions upon the person of one 
individual. 

Erythematosus. Having a reddish blush 
Essentialis. Idiophatic. 

Exfoliativus. Having a tendency to exfoliation or shedding from the surface of 
the body. 

Exulcerans. Exhibiting lesions with a tendency to superficial ulceration. 

Facialis. Located on the face, usually as distinguished from the scalp. 

Favosa. Displaying crusts of favus. 

Febrtlis. Accompanied by a febrile process 
Femoralis. Occurring on the surface of the thigh. 

Fibrosus. Composed of fibrous tissue. 

Figuratus. Having a figured appearance. 

Flavescens. Of yellowish hue 
Foliaceus. Resembling a leaf or leaves. 

Follicularis. Concerning the cutaneous follicles. 

Fungoides. Resembling a fungus. 

Furfuraceus. Exhibiting numerous fine, bran-like scales 
Guttatus Of the size of a drop of water. 

Gyratus. Having a serpiginous or gyrate outline, which is usually the result of a 
coalescence of imperfect circles or semicircles. 

Herpetiformis. Vesicular or herpetic in type. 

Hiemalis. Occurring in the winter season. 

Humidus. Accompanied by moisture. 

Hypertrophicus Characterized by hypertrophy 
Hystrix. Having lesions projected or erected like quills 
Imbricatus. With crusts or scales overlaid like tiles. 

Impetiginodes. Pustular. 

Infantilis, c curring in infancy. 

Intertinctus. Distinguished by color. 

Iris. Occurring in more or less distinctly defined concentric rings. 

Labtalis. Occurring upon the surface of the lip. 

Lenticularis Of the size of a small bean. 

Lividus. Deeply colored. 

Maculosus. Discolored. 

Madidans. Characterized by moisture. 

Marginatus. Having a defined margin. 

Medicamentosus. Produced by external or (more commonly) internal medication. 
Mel anodes. Of blackish color. 

Miliaris. Of the size of a millet-seed. 

Mitis. Of mild, benignant type—the reverse of agrius. 

Multiformis Exhibiting simultaneously several types of elementary lesions. 
Neonatorum. Occurring in the newborn. 

Neuriticus. Having nervous association. 

Nigricans. Of a black or blackish color. 

Nodosus. With development of nodes or tuberosities of the surface. 

Nummularis. Of the size of small coins. 

Oleosus. Accompanied by an oily secretion. 

Palmaris. Occurring on the palms. 


GENERAL ETIOLOGY . 


61 


Parasitarius. 1 r> J J , 

Parasiticus, j ^ roducecl by an animal or a vegetable parasite. 

Patch. The aggregation of several isolated or confluent lesions. 
Phlegmonosus. Accompanied by deep-seated inflammation. 

PHLYCTiENOiDES. Characterized by groups of small vesicles. 

Pigmentosus. Accompanied by pigmentation. 

Pilaris. Related to the hair. 

Plantaris. Situated on the soles of the feet. 

Planus. Flat. 

Polymorphous. The Greek equivalent of the Latin multiform. 

Pr^putialis. Situated upon the prepuce. 

Progenitalis. Situated upon the exposed mucous surfaces of the genitalia. 
Pruriginosus. Accompanied by itching. 

Pubis. Located upon the skin or hairs of the pubes. 

Punctatus. Occurring in dots or points. 

Rhagadiformis. Fissured, or tending to produce fissures. 

Rosaceus. Having a rosy or pinkish hue. 

Ruber. Red, usually dark red in color. 

Scutiformis. Having the shape of a shield. 

Sebaceus. Concerning the sebaceous glands or their secretion. 

Senilis. Occurring in advanced years. 

Serpiginosus. Literally, creeping—advancing in irregular gyrations. 

Siccus. Dry, unaccompanied by moisture. 

Solitarius. Having an isolated lesion, or with isolated lesions. 
Symmetricalis. Similarity distributed on the two lateral halves of the body. 
Toxicus. Poisonous. 

Uniformis. Exhibiting lesions all of one type. 

Universalis. Affecting the entire surface of the body. 

Urticatus. Accompanied by wheals. 

Uterinus. With association of uterine disorder. 

Yariegatus. Exhibiting several distinct colors. 

Vasculosus. Accompanied by vascular development. 

Vernalis. Occurring chiefly in the spring of the year. 

Versicolor. Exhibiting several shades of the same color. 

Vulgaris. Of the usual or commonly observed type. 


III. GENERAL ETIOLOGY. 


The study of the causes of skin diseases gives a glimpse of the 
etiology of diseases in general. In the lowest representatives of life 
the greatest dangers to existence originate in exposure to assault from 
other and stronger representatives in search of their prey—in other 
terms, an external danger. In man, the highest representative of the 
animal scale, the perils of existence are complicated by his social neces¬ 
sities and his artificial methods. He can never, however, at any period 
of his existence, divest himself from the necessity of exposure to ex¬ 
ternal peril. The plan of his organs and the play of his normal 
activities are perfect, even to the recovery from all but mortal injury 
and repair of moderate loss. The struggle for existence of the ideal 
man is intended to be with that which is without; his body meanwhile 
furnishing him with a comfortable tenement and a fair fortress. In 
the purview of nature there should be no internal revolt. TV hen such 
occurs it is usually the result of his ignorance, his folly, or his vice. 



62 


DISEASES OF THE SKIN. 


Viewed in this light, the causes of the diseases of the skin will be 
seen to differ but little from those which induce disease in his other 
organs. Exposed to cold, he suffers from a pneumonia; to injury, a 
fracture or a dislocation; to the contact of poisons, he vomits or 
purges; to contagion from his fellow-man, he has the cholera or plague; 
all these are capable of producing diseases of the skin. But mean¬ 
time his organs have a tender care for themselves and for one another, 
compared with which the solicitude of a mother for her child becomes 
insignificant. The stomach refuses to digest itself; the lung, unwouuded, 
admits no air to the pleura; the bladder, so long as it is unruptured by 
violence, permits no drop of urine to pass into the peritoneal sac. In 
the same proportion, and under the same general law, do the viscera 
refuse to generate a poison which will injure the integument, and the 
fluids of the body, a vicious u humor** which will damage the bones. 

Reasoning thus from analogy alone, it will be seen that the preva¬ 
lent doctrines respecting blood-poisons of internal origin must be greatly 
restricted. Eczema alone, in its manifold forms, furnishes more than 
one-half of all the diseases of the skin; and yet many of these several 
forms can be produced at will and artificially upon the integument of 
man. 

Again, it is not to be forgotten that the body is really invested with 
a continuous skin which not only is extended over its outer surface, 
but is also reflected so as to line all passages by which it is traversed 
within. This inner investment, called the 11 mucous membrane/* is 
as truly a part of the skin as are the epidermis and corium of the face 
or the hand. The truth of this statement is shown first by the facts 
of evolution, since representative animals of the lower scale are found 
capable of complete inversion, by which the outer becomes the inner, 
or digestive skin, and the inner, in turn, becomes the outer or protec¬ 
tive organ; second, by histology, the anatomical characters of the skin 
and mucous membrane being similar; third, by pathology, the extro¬ 
verted mucous membrane rapidly undergoing the transformation which 
causes it to resemble the skin. Furthermore, the inverted skin, as 
when the thighs are by disease kept in continuous contact and moist¬ 
ened, assumes the characteristic features of mucous membranes. In 
the study of cutaneous etiology it is manifestly proper to regard as of 
external origin all causes which operate from without upon either the 
outer or the inner skin of the body. 

t This much premised, it can be said that the large proportion of all 
diseases of the integument originate either from the action of solar 
heat and light; temperature-changes at the surface of the body; con¬ 
tact with various fluid and solid substances with the production of 
either frictional, traumatic, or toxic effects; or the encroachment of 
parasites upon or within the skin. It remains merely to consider the 
causes somewhat in detail, remembering that at times several influences 
co-operate in the production of a given effect. 

The action of solar light upon the skin is usually coincident with the 
operation of another mode of motion called “ heat.** To solar light 
is to be attributed the production of freckles, tan, and other pig¬ 
mentations of the surface; to heat are to be attributed the erythemt 


GENERAL ETIOLOGY. 


63 


the eczema, and the various grades of dermatitis which may follow 
exposure to the direct rays of the sun. Other temperature effects, 
including those produced by extremes of both heat and cold, are to be 
classed in the same category. According to Hebra, exposure of the 
skin to a temperature over 100° F. produces merely a transient ery¬ 
thema, which under a further elevation of 65° F. will not subside for 
several days. At a temperature of 212° F. all grades of acute der¬ 
matitis are awakened, with the production of bullae, up to the point 
where complete destruction of the integument occurs. 

The influence of the seasons is of the same general character. Some 
cutaneous diseases are worse in summer; others in winter. Prickly 
heat (lichen tropicus) is peculiar to certain warm seasons; frostbite and 
its subsequent hypersemia, exudation, or gangrene, occur in winter; 
pruritus is common in cold weather; erythema multiforme is most fre¬ 
quent in the autumn and the spring. 

The questions originating when considering the influence of climate 
are so complex that they are differentiated with difficulty. They 
involve the study of soil, potable water, diet, atmospheric humidity 
and temperature, and the sociological conditions of a given locality. 
Pellagra is said to originate in certain countries from the diet of the 
people. The severe forms of ringworm observed in India result prob¬ 
ably from exuberance of vegetation in the parasite under the influence 
of heat and moisture. The aggravated species of scabies seen in Nor¬ 
way is doubtless the product of filth and cold, with the itch-mite as an 
exciting cause. It must, however, be admitted that the more extensive 
the study of those diseases claimed to be peculiar to given localities, the 
less are they found to depart from the types recognized in other countries. 

Frictional effects are perceptible in the action of the clothing upon 
the skin. Coarse flannel is known to excite pruritus, especially when 
aided by profuse sweat and the muscular movements of' labor. Trusses, 
corsets, napkins, “ pads,” supporters, crutches, orthopaedic apparatus, 
hatbands, stockings, garters, and a long list of similar articles, espe¬ 
cially when soiled with physiological or pathological secretions, are 
responsible for many disorders. Considering the occupations of men, 
bakers, masons, confectioners, blacksmiths, tailors, and an equally 
long list of laborers and tradesmen suffer from the results of friction, 
to which is often added the influence of traumatism or the action of 
chemical irritants. 

Traumatism plays a most important part in cutaneous etiology. It 
includes the action in scratching, of the nails, the knees, heels, elbows, 
etc., as well as the influence of several articles used for the same pur¬ 
pose—pieces of cloth of various kinds, etc. In this way excoriations, 
and even infiltrations of the skin, are induced. Under the head of 
traumatisms should be considered also injuries of the skin-surface pro¬ 
duced by animals, occasionally with the added effect of a toxicant. 
Here are included the wounds produced by lice, fleas, bugs, and acari; 
the bites of serpents, horses, dogs, and cats; and the accidents pro¬ 
ducing traumatism of every kind, not omitting the intentional wounds 
inflicted by the surgeon and their results. 

Toxicants operate upon the skin-surface with and without the produc- 


64 


DISEASES OF THE SKIN. 


tion of traumatism. Thus, the worker in dyes and the wearer of the 
dyed garment manufactured may suffer alike; while vaccination, when 
it produces a generalized exanthem, operates first in the wound made 
by the lancet of the vaccinator. Medicaments used upon the outer 
skin, such as mercury, croton oil, iodin, antimony, and nitrate of silver, 
are capable of engendering disease; aud those which, being swallowed, 
operate as irritants to the inner skin or mucous membrane, may have 
a similar effect. Others being swallowed, and subsequently absorbed 
from the gastro-intestinal tract, produce a toxic effect upon the skin 
in the effort to eliminate them. Thus, the bromid and iodid of potas¬ 
sium, quinin, arsenic, copaiba, and many other articles of the materia 
medica, occasion erythematous, vesicular, pustular, and bullous rashes 
of variable persistence and different external characteristics. 

To this class of toxicants must be added the articles of food and 
drink, which, under ordinary circumstances, and perhaps to the major¬ 
ity of individuals, serve to nourish the body, but yet operate as poisons 
to the few. Thus, alcoholic drinks, shell-fish, preserved meats, certain 
fruits, cheese, pickles, and many other dietary articles, are known to 
originate or aggravate pruritus, urticaria, eczema, and acne. Cracked 
wheat, Graham bread, oatmeal, and buckwheat have been found in 
certain susceptible individuals to induce pruritus, urticaria, and occa¬ 
sionally decided roughness of the skin. Any digested or indigestible 
article of food may excite similar effects at one time and not at another 
in the same individual, the resulting difference being due to the varying 
conditions of the alimentary canal. 

An important list of toxicants is furnished by the micro-organisms 
destitute of chlorophyll, whose pathogenic effects depend either upon 
their presence in the blood or the tissues, or upon the special toxin 
generated after their invasion of the body. Among these organisms 
may be named the staphylococci found in pus, the streptococci of ery¬ 
sipelas, and the bacilli of tuberculosis, lepra, and syphilis. All these 
are external sources of disease. Some require traumatism for their 
introduction into the system, some do not, and some are capable of 
introduction both with and without traumatism. 

Some cutaneous diseases are produced by the growth of the vegetable 
parasites upon and within the skin and hairs, and in the follicles. To 
this class belong ringworm of the scalp, the beard, and the skin; tinea 
versicolor; and favus. 

Of the causes indicated, it may be said that no one of them is neces¬ 
sarily productive of the diseases named. The majority of men and 
women expose themselves daily to the action of light and heat, are 
subjected to friction, suffer from wounds of the integument, and come 
in contact with toxic agents, without exhibiting a disease of the skin. 
Often there is a marked degree of sensitiveness of the integument 
peculiar to the individuals who suffer, that may exhibit itself in several 
members of one family, or may exist in one" person for but a brief 
period of time. Again, an individual idiosyncrasy may be exhibited 
in consequence of which an article, harmless to all others, becomes to 
one person only a source of serious discomfort. 


GENERAL ETIOLOGY. 


65 


The various physiological changes of the human body are never the 
causes of diseases of the skin, but at times they furnish special oppor¬ 
tunities for the operation of such causes. Thus, in the rapid tissue- 
evolution of early life eczema and lupus are relatively common—car¬ 
cinoma and tinea versicolor rare. At puberty the hairs of the beard 
of the male are liable to the incursions of the trichophyton; and the 
nipple and breast of the woman become the seat of eczema from 
epiphora of milk. The old man or the old woman may become the 
victim of cancer, aggravated forms of pruritus, or horny growths. 
Dentition, menstruation, pregnancy, and the menopause each disturb 
the physiological equilibrium, and at times render the access of other 
disturbing forces exceptionally facile. The sexual appetite leads to 
excesses which bear fruit in attacks of herpes, pruritus, and syphilis; 
and the unceasing excretion from the skin-surface, with constant deposit 
there of effete material, may, when there is prolonged disregard of the 
laws of cleanliness, induce a liability to disease of the skin that is 
especially marked in the case of infants and children. 

The power to transmit skin disease by heredity is of less importance 
than is generally supposed. It is most conspicuous in the instance of 
hereditary syphilis; but even here the transmission of the disease is not 
without singular exceptions, and is limited to certain periods of the 
disease in the progenitors. The transmitted disease is also most com¬ 
mon in the foetus, which is in direct communication with the mother, 
and rapidly diminishes in frequency with every month of separate 
existence. As a rule, the disease manifests itself before the fifth 
month of infancy. The instances in which the first symptoms appear 
much later in life are rare. Many of the examples cited of hereditary 
transmission of cutaneous diseases are, without doubt, cases of coin¬ 
cidence, which, considering the number of patients affected annually 
with eczema and psoriasis, for example, should not be regarded as of 
very rare occurrence. 

The list of causes recognized as directly productive of diseases of 
the skin are, without question, under special circumstances, capable of 
operating as indirect etiological factors. Temperature-changes, con¬ 
tacts with the external world in all harmful degrees, and toxicants are 
prime agents in the production of disease of internal organs, and these, 
in turn, may induce changes in the skin, of the nature of disease. 
The uterus, the stomach, the liver, the kidney, the heart, the nervous 
centres, and the intestinal tract may become disordered, and the result 
be declared not only in disturbance of the function of these organs, 
but also in an attack of urticaria, pruritus, jaundice, or erythema. 

Without attempting to decide whether the preponderance of evidence 
is in favor of internal or external causes as productive of the greater num¬ 
ber of cutaneous maladies, it is certain that to many of them disorders of 
the digestive tract sustain a most important relation. Thus, the several 
conditions included under the somewhat indefinite term dyspepsia, gout, 
habitual constipation due to torpor of the intestinal tract, a portal cir¬ 
culation impeded by functional disturbance of the liver, and many other 
affections of the alimentary canal may each be productive of cutaneous 
accidents or complicate the results of the latter. In the same proportion, 


66 


DISEASES OF THE SKIN. 


diseases of the kidneys, the suprarenal capsules, the spleen, and the 
generative organs of both sexes may induce or be complicated by dis¬ 
eases of the skin. 

The influence of the nervous system, when considered in this con¬ 
nection, may be either directly or indirectly exerted. There is scarcely 
any efflorescence upon the surface of the integument, the arrangement 
of whose lesions is not in part determined by the nerve-fibres whether 
with or without the intervention of an effect upon the blood-vessels. 
Both vaso-motor and trophic nerve-fibres are capable of inducing skin 
changes either after direct lesion or stimulation of the nervous centres, 
or through the medium of the latter after peripheral accidents of the 
same kind. Passive congestions of the surface, leading to oedema and 
violaceous blush of the skin, often result from circulatory changes; and, 
in fine, any constitutional disease, by impairing general nutrition, 
arresting repair, hastening waste, or in other directions impoverishing 
the protoplasm of the body, is capable of inducing disorder of the skin 
as in other organs. Thus, in cancer, chlorosis, anaemia, and cholera 
there are significant alterations in the hue of the integument that not 
merely possess a diagnostic value for the clinician, but also attest the 
sympathetic unity of each organ of the body with all others. 

There are authors who affirm, with eminent French dermatologists, 
that certain states or diatheses explain the origin of many cutaneous 
maladies. These diatheses, whether termed arthritic , dartrous , lithce- 
mic, or herpetic , cannot be demonstrated as efficient causes for the pro¬ 
duction of the diseases attributed to them. The chief exponents of 
this theory are not agreed among themselves as to the names of such 
supposed systemic conditions, nor as to the symptoms by which they 
are betrayed, nor as to the exact method of combating their effects. 
The claim that these states are of a nature analogous to a tuberculous 
or a syphilitic diathesis is to-day well-nigh deprived of foundation, 
since the bacterial origin of tuberculosis is assured and that of syphilis 
is at least on the road to demonstration. The complexus of symptoms 
characterized by evolution without demonstrable cause, by frequency 
of recurrence, by obstinacy under treatment, and by alternation of 
cutaneous with other maladies, is no proof of a diathesis, but rather of 
the failure of science to appreciate perfectly all the several conditions 
which produce the result. The cutaneous symptoms which often accom¬ 
pany the group of phenomena so well described by Da Costa 1 as charac¬ 
teristic of lithsemia, are neither constant, uniform, nor peculiar. While 
no wise physician would hesitate to treat patients for the relief of such 
states when there was coincidence of skin disease, he would not, there¬ 
fore, even after coincident relief of the entire group of symptoms of 
disease, be justified in attributing one part of this group to a constant 
association with the others in the case of all patients. 

Without attempting fully to discuss or to settle these questions, it is 
necessary to establish the fact that the eruptive phenomena in any skin 
are produced by a multitude of ever-shifting and varying combinations 
of causes. Even the syphilodermata are influenced from hour to hour 

1 The Nervous Symptoms of Lithsemia. American Journal of the Medical Sciences, 1881, p. 313. 


GENERAL DIAGNOSIS. 


67 


by drugs swallowed, by external irritants, and by conditions of the 
general health, such as transitory diarrhoea, or a fit of coughing. In 
the light of our present knowledge, it is the part of the physiciau, on 
the one hand, to neglect consideration of no efficient factor in the origin 
or evolution of a cutaneous disorder; and, on the other hand, to refuse 
to assign to a diathetic state only, a group of symptoms which may 
occur in persons where no such systemic conditions can account for 
the evidences of disease. 


IV. GENERAL DIAGNOSIS. 


The establishment of an accurate diagnosis in cutaneous diseases is 
essential to their successful management. This statement is rendered 
necessary in this connection by the prevalence of a belief among the 
uneducated that the disorders of the skin, exhibited for the most part 
in visible symptoms, can safely be treated on general principles, with¬ 
out a recognition of the nature of the malady. By many practitioners 
the demand for an accurate diagnosis is ignored in consequence of a 
too general impression that the desired end is to be pursued through 
great and perplexing obscurity. Yet with patience, method, a habit 
of careful observation (without which no physician is successful), and 
a reasonable degree of skill, both practitioner and student can, in the 
large proportion of all cases, attain their purpose. 

It is a popular error that the sole requisite for establishing a diag¬ 
nosis is the exhibition of an affected portion of the integument to the 
eye of him who is consulted with a view to its relief. The physician 
is supposed to inspect this surface attentively for a few moments, and 
then to pronounce definitely upon the nature of the disease present, and 
the therapeutic measures to be adopted; but far more than this is requi¬ 
site, and, indeed, is fully as essential here as in the investigation of 
disease involving any other organ of the body. 

It is first necessary to secure a history of the physical and mental 
condition of the patient in the past; then should follow the special his¬ 
tory of the disorders of the skin; lastly, an examination of the affected 
integument. For the purpose of methodically arriving at these facts, 
and of preserving them for future reference, they should systematically 
be recorded. The following are some of the points upon which it will 
generally be found useful to secure information: 

The name, residence, age, sex, occupation, and married or unmar¬ 
ried state of the patient should be known, as also, whenever practicable, 
the health-history of parents and children. In the case of women it 
is not only necessary to learn the history of the menstrual function in 
the past, but it is of the highest importance to be informed also as to 
the previous occurrence of abortions and miscarriages, and, if such 
have occurred, the order observed by these with relation to the birth 



68 


DISEASES OF THE SKIN. 


of viable infants. The significance and value of several of these facts 
have been described in the chapter on Etiology. With respect to the 
history of the products of conception, it should never be forgotten that 
they have a most important bearing upon the question of syphilitic 
infection. The absolute exclusion of syphilis in any obscure case is a 
long step in the direction of an accurate diagnosis. In the instance of 
male patients, questions will usually elicit either admission or denial 
of the fact of a precedent or present venereal disease, and the answers 
should be regarded as valueless or trustworthy according as they are 
or are not substantiated by corroborative clinical facts. 

Then should follow some record of the habits of the patient, as to 
active or sedentary employment, bathing, food, and drink, including 
under the latter term the use of beer, wine, and spirits. The history 
of any previous disorders, whether of the skin or other organs, should 
be satisfactorily clear, and, with respect to the latter, the dates of occur¬ 
rence, recurrence, and convalescence be at least approximately discov¬ 
ered. The patient should also make known whether he has had refresh¬ 
ing sleep; whether he has undergone mental anxieties (domestic, 
financial, etc.); whether he has suffered in his digestive, respiratory, 
circulatory, genito-urinary, or nervous system. 

This much ascertained, the patient should be encouraged to narrate 
as succinctly as possible, and as far as may be in his own terms, the his¬ 
tory of the present cutaneous disorder. He should describe the subjec¬ 
tive sensations it has produced, as also the objective features presented 
to his own vision and touch. In the case of infants this information 
will, of course, have to be obtained from the mother or the nurse. 
The treatment to which the disease has been subjected should then be 
detailed, this frequently furnishing a key to the diagnosis and therapy 
of the disorder. In an incredibly large proportion of all cases, ignor¬ 
antly directed and vicious internal or external medication has either 
begotten or aggravated the disease of the skin. This much ascertained, 
the physician is ready to examine the affected surface for himself. 

During, however, the verbal interrogations which are required for 
this part of the exploration of the case, the watchful and observant 
practitioner will probably have secured for himself some useful infor¬ 
mation of which the patient is totally unconscious. Much of this is 
difficult to describe, as it is the rich fruit of a wide experience and 
careful scrutiny. With a gentle, courteous, and sympathizing manner, 
the diagnostician must combine the art of a detective and the skill of 
a swordsman. Glancing occasionally at the face of his patient while 
making record of the answers given, he will, of course, have observed 
any eruption upon that portion of the body. He will have made a mental 
note of the temperament of the sufferer, and of any movement made by 
the latter indicating a tendency to scratch or rub portions of the skin. 
He will have noticed the posture, clothing, and head-apparel; the 
existence of hair on the scalp or extensive baldness; the condition of 
the exposed hands as indicating manual labor or the reverse; and in 
the absence of facial lesions, will have observed the special tint of 'the 
skin of the face, as suggesting anaemia, chlorosis, or a general condition 
of cachexia. The facial expression, as indicative of anxiety or placidity 


GENERAL DIAGNOSIS. 


69 

habits of debauch, sexual excesses, etc., will not have escaped his 
attention. All this and much more will possibly have enabled the 
questioner to direct his interrogatories into the channel where they will 
elicit the most useful responses. The posture, cries, facial expression, 
and general condition of nutrition of the infant will have been no less 
carefully noted. 

Proceeding to the examination of the affected integument, the phy¬ 
sician must assure himself of a good light, as colors are best distin¬ 
guished by daylight, and artificial illumination should be reserved for 
exploration of the cavities of the body. The air of the apartment 
should be sufficiently warm to permit of exposure of the person with¬ 
out discomfort. Adult males and children of both sexes should have 
the clothing completely removed, so that all portions of the skin may 
be inspected. One portion of the body may, however, be examined, 
and then covered, if desired, while the examiner proceeds to direct his 
attention to another. In the case of women the investigation should 
be conducted with all the tact and delicacy to which the sex is entitled. 

The examination, whenever practicable, should extend over the entire 
surface of the integument. The importance of this point can scarcely 
be exaggerated. It must be remembered that the physician should be 
very much wiser than his patient, and the assurances of the latter are 
always to be accepted with reserve. Thus, one who merely exposes his 
leg, stating that this is the only part of his body affected, may have 
concealed beneath his clothing extensive varicosities of the veins of 
the thigh, a typical syphilitic exanthem over the belly, a significant 
scar on the elbow, an extensive patch of tinea versicolor on the surface 
of the chest, or a blennorrhagic discharge from the urethra, the medi¬ 
cation of which has induced the rash for which he seeks relief. These 
are not the rare, but are the common cases of a daily experience. 

Observation should be had at this time of the general and special 
features of the eruption. As to the former, the following considera¬ 
tions should be borne in mind : 

A symmetrical eruption, one equallv distributed over the two lateral 
halves of the body, is rarely the result of au etiological factor operat¬ 
ing upon the outer skin. It more often points to an efficient cause of 
so-called “ internal ” origin, one influencing the inner skin or the inter¬ 
nal organs. An eruption affecting the covered integument, never creep¬ 
ing out upon the exposed surfaces, suggests the operation of the 
clothing, as the latter may chance to prove the nidus or protector of a 
parasite, the fabric which has been colored by a noxious dye, the 
recipient of a chemically altered secretion, which has proved irritating 
to the surface, the instrument of friction, or the source of increased 
temperature at the surface by its non-conductivity of heat and unsea¬ 
sonable thickness. An eruption, accompanied by excoriations and 
scratch-lines, is usually severest in the parts most accessible to the 
hands and least developed where the latter have the least play, as 
over some parts of the back. An eruption limited to the hands is 
likely to be one induced by an agent to which the hands alone have 
been exposed. Such are the eruptions originating in the trades and 
domestic occupations; in the latter, an eruption more distinct on the 


70 


DISEASES OF THE SKIN. 


right hand, and especially about the right thumb and index finger, 
tells its own story when the hand-worker is not ambidextrous nor left- 
handed. Artificially and intentionally produced eruptions, as in malin¬ 
gering, hysteria, mental depravity and insanity, usually occur also in 
parts to which the right hand finds easy access. 

Eruptions occurring on the face, the hands, and the genitalia of men, 
or on the face, hands, and mammae of women, point to external contact 
or contagion (poison-ivy, scabies, croton-oil, etc.); since, next to the 
face, the hands are more commonly brought in contact with the parts 
named in the sexes respectively, as the wearing-apparel of each suggests. 

An eruption limited to the forehead suggests an inspection of the 
hatband, the veil, or the overlying false hair; to the ears of women, 
a glimpse at possibly cheap ear-rings; to the centre of the root of the 
neck, before or behind, a scrutiny of the collar-button and collar; to 
the anus of the baby, an inquiry as to the changing of its napkins; 
to the wrists of the adult, a question as to the cutis worn; to the feet, 
information respecting gaiters, varicose veins, recently cut corns, and 
ill-fitting shoes. Eruptions springing from each of these causes have 
long and vainly been treated as 11 diseases of the blood. ” 

Eruptions markedly asymmetrical are indicative of asymmetrically 
operating causes—that is, the accidents of environment, or else influ¬ 
ences exerted within the body unequally on its two lateral halves. 
Thus, an orthopaedic apparatus, worn to correct talipes, excites a der¬ 
matitis of the leg only of the affected side; and zoster of the trunk is 
evident on that side supplied by the intercostal nerve which has been 
inflamed. The greater stress may be laid on this peculiarity, as the 
law of symmetry, in eruptions not occasioned by causes operating on 
the outer skin, is faithfully observed in nature. The earlier syphilides, 
the quinin exanthem, rubeola, and even lupus erythematosus, are 
remarkable illustrations of this fact. 

Proceeding next to the special visible characteristics of the eruption, 
the physician will not fail to note an acuteness or chronicity of lesions, 
their color, size, distribution, and tendency to become aggregated in 
patches, or the reverse, and the evidence presented as to change in 
type, the sequence or coexistence of several lesions at the same time— 
that is, the multiformity (polymorphism) or uniformity of the eruption. 
He will observe whether the limit of the affected skin is well defined 
against that which is normal, or is scarcely to be outlined with a pen 
or a pencil. He will rupture a bleb, puslule, or vesicle, should such 
be found, to discover the nature of its contents. He will remove one 
or several crusts in sight, to expose the surface on which they rest. 
He will scrape away a few scales with the dermal curette for a similar 
reason. He will as carefully inspect the skin where the disease has 
existed, as that where it does exist. He will pinch up between his 
thumb and finger a portion of each part, in order to determine its infil¬ 
trated condition, its atrophy, or its attachment to the tissues beneath. 
He will pass his hands over the surface to recognize the firmness or 
the softness of the lesions, their dryness or moisture, and the exist¬ 
ence of sebaceous or of perspiratory secretion. He will look at the 
mouths of the follicles, where such secretion is retained or is abundantly 


GENERAL DIAGNOSIS. 


71 


exuded. He will discover any lice or their ova on the hair, any ascarides 
at play about the anus, any unnatural formation of the nail or defor¬ 
mity of its matrix. He will examine for inguinal, post-cervical, axil¬ 
lary, and epitrochlear adenopathy, and will thus be often greatly aided 
in his task. This done, he will question in turn for himself, and by 
the methods recognized in medical science, the organs of the body other 
than the skin. He will inspect the tongue carefully, and if then he 
considers himself througli with the mouth, he will be guilty of great 
error. The gums rarely deceive the questioning eye; the inside of the 
lips, the fauces, and the tonsils are all to be searched. A mucous 
patch here will often echo the story of a palmar or a plantar syphilo- 
derm. The laryngoscope may be called for in syphilis, cancer, lupus, 
and leprosy. The degree of distention of the belly and the region of 
hepatic dulness should not be overlooked. The genitalia of men, and 
of children and infants, can usually be explored. For women unaf¬ 
fected with syphilis or disease limited to these parts an exception in 
this particular should usually be made. 

With the necessary reserve of all very obscure cases, it may be said 
that the physician who has conscientiously conducted an examination 
after the manner described above is in possession of the diagnosis for 
which he seeks. If the facts thus acquired have properly been recorded, 
and yet do not spell out such a diagnosis to his eyes, they will probably 
be legible to others with a wider experience or riper judgment, to whom 
such a record may be shown. It is not claimed that this exhaustive 
method of examination is requisite in every case, as, for example, in 
order to recognize an acne or to differentiate erysipelas from erythema. 
But it is certain that few obscure cases of skin disease will remain such 
under severe scrutiny, and the establishment of a thorough and exhaus¬ 
tive method of examination is important in the earliest experience with 
disease. Let the student or the practitioner conduct such an examina¬ 
tion in the first few cases of eruption upon the surface of the body for 
which his advice is sought, and he will establish a habit of observation 
in comparison with which his pecuniary or professional success in the 
management of the same cases will indeed be of trivial worth. 

Upon one special point should the inexperienced physician be 
guarded. It relates to the acceptance of a diagnosis which is not based 
upon such an examination as that given in outline above. A diagnosis 
by a patient is usually faulty, and the verdict of even skilled practi¬ 
tioners may be founded upon an error. The careful diagnostician 
should begin his task in a spirit of skepticism, and pronounce definitely 
only upon ascertained facts. The mau who says he has an “ eczema ” 
may be louse-bitten; the woman who has been “ overheated , ’ may 
prove syphilitic. The patient recognized as suffering from ringworm 
of the beard may not have been infected under the hands of the barber. 
Finally, the eruptions upon patients unmistakably syphilitic are often 
of other than syphilitic origin. These infected subjects, men, women, 
and children, are exposed daily to the accidents from which the non- 
infected suffer. They exhibit acne, physiological alopecia, and dermatitis 
medicamentosa equally with those who have not sinned sexually. 

The microscope is an instrument whose aid in establishing a diagnosis 


72 


DISEASES OF THE SKIN. 


of cutaneous diseases can rarely be dispensed with. The contributions 
it has made to the knowledge had on the subject of pathology are of 
inestimable value; and as a means of diagnosis it can be used with 
advantage both at the time of the first examination of a patient, and 
afterward for the more leisurely examination of hairs, scales, crusts, or 
portions of tissue. Those unable to secure the costlier and elaborate 
instruments sold by the makers should take pains to provide them¬ 
selves with a fairly good student’s stand and a fifth and a half-inch 
objective, for use in the diagnosis of skin diseases. 

The diagnosis of special diseases of the skin is described in the 
chapter devoted to each. 


V. GENERAL PROGNOSIS. 

The prognosis of most diseases of the human body is formulated 
with a view to the decision of the serious question of life or death. 
Occasionally this question arises in connection with skin diseases. 
Many of the latter are trivial, some are grave, a few are inevitably 
fatal in their termination. Thus, general exfoliative dermatitis, lep¬ 
rosy, sarcoma, carcinoma, at times lichen ruber, and variola in the 
unprotected, are of grave portent; while the ordinary congestions and 
exudations, the great majority of all cases of acquired syphilis in adults, 
and the entirely curable diseases induced by parasites do not excite 
alarm in the breast of the average patient with respect to his longevity. 

The questions, however, as to his future, which are urgently pressed 
by the victim of cutaneous disease, are both numerous and important. 
He is anxious as to the time during which he must suffer; as to the 
possibility of conveying h?s disease to his progeny or other members 
of his family; as to the disfigurement of his person that might result; 
as to the scars which he may have to carry for the remainder of his 
life; as to the possible recurrences of his malady in the future. The 
responses to these questions will largely be influenced by the prognosis 
of the physician. 

Some diseases of the skin are acute, rapidly pursue their course, and 
are then prompt to disappear. Others are chronic, rebellious to treat¬ 
ment of the most energetic and skilful character. Others, again, 
though not shortening life, are never relieved while life is continued. 
Some disappear, only to reappear at more or less regular intervals. 
There are cutaneous diseases which, affect one individual but once in 
his lifetime; others which reappear at the instant the patient is again 
exposed to their exciting cause. There are cutaneous diseases so dis¬ 
torting and destructive in their effects that their victims have committed 
suicide under the influence of the morbid emotions which they have as 
a consequence experienced. 

The mental distress occasioned by even an insignificant cutaneous 



GENERAL THERAPEUTICS. 


73 


disorder is often out of all proportion to its exciting cause, and this 
should always be regarded in establishing a prognosis. The sexual 
hypochondriac has been made insane by an acne; and the man or 
woman affected with syphilis has been made wretched for years by a 
recurrent erythema. 

Again, a disease of the skin may coexist with grave lesions of inter¬ 
nal organs, and the prognosis of the disease of the one be greatly 
influenced by that demanded by the other; thus, there is occasional 
coexistence of syphilis and phthisis. Pruritus may be associated with 
albuminuria; and the eczema of an infant starving for want of breast- 
milk may hasten its marasmus to a fatal termination. 

Upon the answers given to his patient inquiring as to the prognosis 
of the disease of the latter will largely depend the professional success 
of the physician. Scrupulous honesty should here be welded with all 
the skill that science can command. That a disease does not endanger 
life is not an argument in favor of its amenability to treatment. The 
practitioner should never suffer himself to be pushed by his patient to 
the position that an obstinate disease is readily manageable. It is the 
height of folly to estimate lightly that zoster of the forehead, the scars 
of which the patient may exhibit to all who afterward look upon his face 
both in life and in death. He who engages to relieve an alopecia areata 
in the month may have a year in which to repent his precipitancy. 
There is no way in which the conscientious physician can so readily 
secure the confidence of his patient, and with it that willingness to 
submit to appropriate treatment, which is begotten of such confidence, 
as by demonstrating his ability to forecast the future of a disease; in 
other words, to describe accurately its prognosis. 


VI. GENERAL THERAPEUTICS. 


A CONSIDERATION of the subject of the methods of treating skin 
diseases in general suggests at once the intimate relation which subsists 
between the integument and other organs of the body. The etiology 
of one largely explains the causes of the disease in all. The patholog¬ 
ical processes in each are subordinated to the same general laws. The 
principles of treatment are very similar in all the disorders of the body. 

The object to be attained by treating a cutaneous disease is, first, 
its complete relief; second, where relief is impossible, such manage¬ 
ment of the morbid process as will mitigate its severity and render 
the victim of the disease more comfortable. A higher and more scien¬ 
tific achievement than either is the prophylaxis by which man is enabled 
to escape the disease altogether. He can by his wisdom largely dimin¬ 
ish the danger to which his integument is exposed ; he can, to a certain 
extent shelter himself from extremes of temperature, traumatism, 



74 


DISEASES OF THE SKIN. 


toxic agents, and contagious diseases; he can, by observing the simple 
rules of hygiene, fortify his skin against the lesser evils which may 
befall it. If it be true that “ the people perish for the want of knowl¬ 
edge,” it is certain that, once in possession of it, they can greatly 
enhance their comfort and prolong existence. Here, however, the 
subject under consideration involves disease which is actually present 
and in progress. 

Like all other diseases of the body, those of the skin may be divided 
into three classes with relatively fixed limits. 

The first class embraces all the diseases which have a natural ten¬ 
dency to pursue their course to a favorable termination. It embraces 
all those affections which, either mild or severe, require absolutely no 
treatment of an active character. It is the duty of the skilful physi¬ 
cian to watch the evolution of these maladies, and to discharge a most 
important part by refraining from all therapeutic measures which in 
such cases might prove hurtful. By his judicious counsel, also, he 
hinders patients and their friends from pursuing a course which might 
prove prejudicial to the disease. 

The second class embraces all those skin affections which are either 
inevitably fatal or hopelessly remediless while life is prolonged. For¬ 
tunately, this includes but a small proportion of the large list. Here 
the duty of the physician is plain. He should assuage pain, attempt 
to relieve deformity, administer to the comfort of the afflicted in other 
ways, and, by his patient courage, inspire confidence aud hope. It 
must not be forgotten that the skill of man has not yet reached the 
acme of human need. In the presence of many diseases of the body 
he stands absolutely helpless, and the speediest way to success in such 
cases is to begin by an honest admission of the plain fact. 

The third class of affections naturally embraces all not included in 
the first two. Here disease may be prolonged or be shortened in its 
course, rendered acute or chronic, made more or less endurable, per¬ 
mitted to become .inveterate, or absolutely be relieved by prompt and 
energetic measures, according as it is, or is not, judiciously and skil¬ 
fully managed. Here are gained the most brilliant successes of the 
dermatologist; here also occur his most humiliating failures. 

In the presence of a cutaneous disease which requires treatment the 
question naturally arises as to whether this treatment shall be internal, 
that is, by medicaments ingested, or external, that is, by local thera- 
peusis, or by combination of the two methods at the same time. 


1. Internal Treatment. With regard to the question of internal 
treatment, which is one of pressing importance, it can safely be said 
that there are no remedies to be given by the mouth that can be de¬ 
scribed as certainly and specifically curative of the diseases of the skin. 

• 6 i J ne< ^ c i na l agents employed with this end in view is 

incredibly arge, by far the greater part being obtained from the vege- 
taWe kingdom. With few exceptions, some of which are enumerated 
below, the most esteemed of these agents exert only an indirect therapeu¬ 
tical effect upon the integument. The larger number of medicaments 



GENERAL THERAPEUTICS. 


75 


thus used are, it must be admitted, without value of any kind, but 
will probably continue to be vaunted as possessing specific virtue so 
long as credulity on the one hand, and avarice on the other, move 
the mass of mankind. 

Arsenic has long stood at the head of the list of remedies as valu¬ 
able, when ingested, for the relief of cutaneous disorders. It is known 
to exert its effects almost exclusively upon the epithelia of the skin, 
and upon these, so far as therapeutic effects are concerned, only when 
they are the seat of subacute and chronic exudation. It is known to 
exert an unfavorable influence upon the epidermis when the latter is 
in a condition of active inflammation, and if given for long periods of 
time may produce keratosis of the palms and soles. Operating favor¬ 
ably in this limited class of cases, it also operates slowly, requiring 
months for the production of its curative effects. Its administration 
is at all times attended with the hazard of producing toxic effects, 
which, however, when the result of the exhibition of the drug in 
medicinal doses, are usually limited to a mild exanthem upon the skin, 
moderate coryza, and some redness from congestion of the vessels in 
the eyes and eyelids. 

Arsenic is used chiefly in psoriasis, acne, squamous eczema, pem¬ 
phigus, and lichen ruber ; its dosage in cases of children being relatively 
large. It should invariably be administered only after eating, and a 
minimum dose be first employed in order to test the susceptibility of 
the patient to its action. It should be remembered that the toxic 
effect of this, as also of several of the other drugs mentioned below, is 
often speedily noticed after the first exhibition of a relatively small dose. 
Toleration once established, the dosage may cautiously be increased. 

r Fhe forms in which arsenic is usually administered are the prepara¬ 
tions of arsenious acid, such as the liquor potassii arsenitis (Fowler’s 
solution); the liquor arsenici et hydrargyri iodidi (Donovan’s solution); 
the liquor arsenici chloridi: and the Asiatic pill. Duhring’s modifi¬ 
cation of this pill is obtained by making 2 grains (0.13) of arsenious 
acid, and 32 grains (2.2) each of black pepper and licorice powder into 
thirty-two pills by the aid of a sufficient quantity of mucilage. Arsenic 
is also at times advantageously combined with other indicated medici¬ 
nal substances, such as iron and the iodid of potassium. 

In the first edition of this treatise it was stated that an unprejudiced 
view of its action, even in cases properly selected for its internal admin¬ 
istration, would justify the conclusion that arsenic is in diseases of the 
skin a remedy of uncertain effect, and, in that proportion, disappoint¬ 
ing. Subsequent investigation, made particularly by American obser¬ 
vers, has more than established this position. Fox, 1 after collation 
of the experience of a number of American experts, concluded that 
the common practice of giving arsenic in many cutaneous diseases was 
both harmful and irrational, not merely because of its effect in inducing 
cutaneous congestion and pruritus, but also because of the reliance 
placed upon it to the exclusion of other and better methods of treatment; 


i Journal of Cutaneous and Venereal Diseases, June, 1886, p. 179. 


76 


DISEASES OF THE SKIN. 


and that the beneficial effects supposed to follow its administration 
were often due to other causes. He called attention also to the striking 
fact that no series of carefully recorded cases had ever been published 
in which notable therapeutical results had been shown to result solely 
from its administration. 

These conclusions elicited a number of statements from well-known 
physicians having experience in the management of cutaneous diseases, 
who, for the most part, assented to Hr. Fox’s conclusions. Even in 
pemphigus, psoriasis, chronic eczema, and lichen ruber, where this 
remedy has been thought to possess special efficacy, it has in cases 
conspicuously failed. 

It is safest to conclude, first, that arsenic, instead of being one of 
the earliest, should be one of the last remedies to be selected in the 
management of cutaneous diseases by the general practitioner; second, 
that, when thus selected, its value will probably prove greatest if the 
eruptive lesions be seated superficially, generalized, diffused, or in 
evident association with neurotic symptoms ; third, that in any case its 
failure to relieve should not be regarded as definite, if only Fowler’s 
solution has been administered. 

Mercury in the treatment of syphilodermata is of incontestable 
value, and its injudicious employment in many cases springs from that 
precise fact. The vulgar prejudice that many disorders of the skin, 
really not syphilitic, are obscure manifestations of lues in a preceding 
generation and amenable to mercurial treatment, is a striking illus¬ 
tration of the necessity of accurate diagnosis in cutaneous diseases. 
Few non-syphilitic affections are benefited by continuous courses of 
mercury, though the value of the metal as an alterative in this small 
proportion of cases must be admitted. Corrosive sublimate is often 
superseded, in consequence of its irritative effects, by the compounds 
of the metal with iodin. The gray powder is useful chiefly in case of 
infants and children, though its not infrequent development of the 
corrosive chlorid has limited its employment. Calomel and the mer¬ 
curial pill should be employed only for transient effect, as, when 
administered for long periods, they are much more apt to produce 
ptyalism than the other preparations mentioned. 

Iodin and its compounds are also chiefly used in syphilitic disorders 
of the skin, but they possess a wider range of value than the mercu¬ 
rials in the treatment of other cutaneous affections. Here, too, the 
abuse of the drug furnishes a long list of cutaneous disorders either 
orginated or aggravated by its employment. As in the use of arsenic, 
toleration should be established before large doses are exhibited. The 
compounds chiefly used are the iodids of potassium, sodium, lithium, 
and ammonium, and iodoform. Iodin has been administered for the 
relief of the scrofulodermata, lupus, keloid, and syphilitic affections 
of the skin. As to the latter, it may be added that in the earlier symp¬ 
toms of lues it is often a source of positive injury. 

Cod-liver Oil is a remedy of special value in diseases of the skin, 
and was for that reason held in high favor by the distinguished Hebra, 


GENERAL THERAPEUTICS. 


77 


though its action is almost exclusively that of a nutrient of the general 
system. It is employed chiefly for its roborant effects, which are sim¬ 
ilar to those of the digestible aliments. Its special value in the treat¬ 
ment of infants and children affected with cutaneous diseases cannot be 
questioned. It is, moreover, of great use in maturer years, and is 
advantageously exhibited in eczema, lupus, scrofula, syphilis, scle¬ 
roderma, and in all disorders of the integument accompanied by 
wasting. 

Quinin, administered both as a tonic and antiperiodic, is largely 
employed in cutaneous medicine for its generally recognized systemic 
effects. It produces, in certain susceptible individuals, a peculiar 
smoothness and softness of the skin, which usually disappear when the 
drug is suspended. Like arsenic and iodin, it is occasionally the cause 
of a generalized exanthem, and is capable of producing other toxic 
effects, such as failure of the heart’s action, dizziness, and tinnitus 
aurium, symptoms recognized under the designation of cinchonism. 
It will, of course, exhibit its happiest effects in malarial affections 
with coincidence of cutaneous symptoms in the forms of disease of the 
skin associated with a neurosis. 

Ergot, whether by exerting an effect upon the muscle-bundles or 
the vessels of the derma, or upon the uterus, or yet by its influence 
upon the general economy, is thought to possess some value in the treat¬ 
ment of several cutaneous diseases occurring in both sexes. Such are 
acne, purpura, and a few other disorders. 

Calx Sulphurata was once regarded as the most efficient of the 
sulphur compounds for internal use in cutaneous diseases. Its sup¬ 
posed value in furunculosis has led to its employment also in eczema, 
acne, and impetigo. It is given in doses of from y 1 ^ (0.004) to \ 
(0.016) of a grain, three or four times daily. It is, however, a remedy 
uncertain in operation and of dubious effect. Chrysarobin has been 
administered internally by Stocquart 1 and others in doses of (0.01) 
of a grain, for a number of cutaneous disorders. 

Ichthyol, mentioned later as of some value when externally em¬ 
ployed, has also been given by the mouth. 

Jaborandi and Pilocarpin, probably as a result of the free 
diaphoresis which they excite, have unquestionably exerted immediate 
therapeutic effects in a number of cutaneous disorders. 

Sulphur, highly esteemed as a popular remedy in cutaneous affec¬ 
tions, exerts but little influence upon the latter when it is ingested. 
Its cathartic effect is the chief reason for its administration. It is 
recommended by Crocker in some of the disorders of the sweat-function. 


i Ann. de Derm, et de Syph., 1884. 


78 


DISEASES OF THE SKIN. 


Antimony in small doses is of unquestioned value in many diseases 
of the skin. It is, when not contraindicated, employed with advantage 
in cases of psoriasis, pruritus, and some of the obstinate forms of eczema. 

Tar, Carbolic Acid, Creosote, Guaiacol, Resorcin, Turpen¬ 
tine, Copaiba, and Phosphorus are remedies which have been em¬ 
ployed internally with appreciable effect in certain cutaneous maladies. 
They have been used with advantage in cases of lupus, eczema, psori¬ 
asis, and pruritus; but the disagreeable effect of their internal admin¬ 
istration has been to a great degree a bar to their general employment. 
The u perles” of phosphorus, and the elegant elixirs of the same drug 
now in the market, seem to have obviated this difficulty in the instance 
of at least one of these articles. The carbonate of creosote given in 
capsules is usually well tolerated. 

Thyroid Extract and other preparations of the thyroid gland of 
the sheep have, in recent years, been tried largely in various diseases 
of the skin. In myxoedema decided and brilliant results have been 
obtained, and the same is true of some tuberculous affections of the 
skin. The depressing action of thyroid extract on the heart makes it 
an unsafe remedy to use except with great care. 

Unpromising as is confessedly this brief review of the remedial 
influence which internal medicaments are capable of directly exerting 
upon the skin, it must not be forgotten that, while the treatment of the 
patient and the treatment of the patient’s skin are practically one, there 
is some distinction to be drawn between them. No one would claim 
that castor oil, for example, possessed any efficacy in the fracture of 
a femur, yet such a cathartic is frequently ordered by the surgeon, 
with the happiest effect upon the condition of his patient in a splint. 
Such precisely is the inestimable value of a properly conducted internal 
medication in cases of cutaneous disease. 

The consideration of this point introduces at once and properly 
to the broad field of general medicine. He is totally unfit to treat 
cutaneous diseases who is not qualified by education and experience for 
the general practice of medicine. The internal treatment of the patient 
suffering from a disease of the skin is that which is in each case indi¬ 
cated by his general condition. Thus, the aperients, cathartics, diu¬ 
retics, and occasionally even the anodyues, are demanded, and, when 
judiciously employed, they accomplish beneficial results. Few practi¬ 
tioners can afford to dispense with the use of the preparations of iron 
for example, in cases of anaemia. Even the patient affected with a 
parasitic disea-e may need one of the bitter tonics, and the youth with 
vegetations .upon the glans may require first to be rid of his blennor- 
rhagia. 

Among the medicinal substances indicated by the general condition 
of the patient affected with a disease of the skin, yet not directly acting 
upon that organ, none are more useful than the diuretics, cathartics; 
and remedies acting as stimulants to the secretions of the chylopoietic 
viscera. At this day no educated physician believes in employing 



GENERAL THERAPEUTICS. 


79 


medicines with a view to either the so-called u driving out ” or “ driv¬ 
ing in” of a disease of the skin, much less in the use of evacuants with 
a view to carrying off a supposititious materies morbi. The remedies 
suggested above are undoubtedly, for the most part, useful in diminish¬ 
ing the congestion of the cutaneous capillaries, an important point not 
only with respect to the comfort of the patient, but also to the relief of 
his ailment. 

He who accomplishes the largest success will not, finally, neglect 
consideration of the diet, hygiene, and social surroundings of the 
patient. The chief value of many of the mineral springs and health 
resorts of the United States lies in the change of the manner of living 
that they invite and necessitate. Sunshine, pure air, recreation after 
the care and toil of business, change of climate, of foods and drinks, 
and eveu of cooks, often decide the question of speedy recovery. 
Unfortunately, both iu America aud in Europe, many of the health- 
resorts are peopled by unscrupulous charlatans, with a myopic tendency 
to attribute all the benefits to be derived from these sources to the 
medicinal virtues of this or that particular spring, aided always by 
treatment according to their own peculiar methods. Many patients 
affected with disease of the skin are thus made worse by a temporary 
residence at noted health-resorts, aud, therefore, it is often the case that 
a visit to the seashore, the mountains, or to any healthful place in the 
couutry proves conducive to far greater practical results. 

This fact understood, it is admitted that many of the springs of the 
United States possess a therapeutic value in cutaneous diseases actually 
dependent upon the consituents of their waters. A new study of this 
interesting and important subject is demanded by the annual discovery 
of new sources within the borders of the United States, which gives a 
large promise for the future. Many of those ignorantly recommended 
as valuable for the entire list of cutaneous disorders are either entitled 
to no such encomium or may usefully be employed only in a limited 
number of skin affections. Large successes are undoubtedly to be 
credited to the scores of ferruginous, sulphuretted, chlorinated, alkaline, 
arsenical, purgative, and other springs whose names appear in the 
lists given by European writers on this subject. Most of these are 
represented by waters of equal if not greater value furnished by the 
numerous spas of Michigan, Virginia, New York, Colorado, New 
Mexico, Utah, and other States and Territories of the Union. As 
these waters are brought within reach of a larger portion of the popu¬ 
lation of the country by greater railway facilities, their medicinal value 
will be better appreciated, and they will be much more systematically 
employed than at present. They offer a most promising future for the 
internal treatment of diseases of the skin by American practitioners. 


2. External Treatment. In the external treatment of diseases 
of the skin the indications are to hasten repair when this is possible; to 
alleviate distress, if palliatives only are admissible; to destroy abso¬ 
lutely or excise the diseased tissue, when this is justifiable. The fol¬ 
lowing are the principal substances employed as external applications: 



80 


DISEASES OF THE SKIN. 


Water, either pure or medicated by holding other substances in 
solution or mechanical suspension, is applied either in baths or as 
lotions. Baths, local or general, may be employed for days continu¬ 
ously, or but for a few moments at a time. They are given with 
water of varying temperature—cold, warm, or hot. 

Cold baths of short duration are generally followed by a sharp reac¬ 
tion, the skin becoming congested after the normal temperature of the 
surface is regained. It is for this reason that cold sponging of the in¬ 
flamed skin is usually grateful so long as it is continued, and is succeeded 
by an aggravation of the symptoms which it was intended to relieve. 
Continued applications of cold water are not open to this objection. 

Hot baths are followed by a more or less enduring relaxation of the 
integument, while tepid-water baths are chiefly macerative of the sur¬ 
face. It should be remembered that the application of watery lotions 
to the broken surface of the skin is liable to be followed by endosmosis, 
unless the specific gravity of the serum of the blood and that of the 
fluid of the bath or the lotion are nearly the same. This imbibition 
of fluids by the broken skin is accompanied by slight swelling of the 
tissues and is productive of disagreeable sensations. 

The most perfect of all applications of water to the surface of the 
body is that most resembling the water-bath in which the tender skin 
of the foetus is safely immersed for consecutive months. Here the 
bath is continuous; the temperature is that of the viscera of the 
living animal; and the delicate skin of the unborn child is anointed 
with a fatty substance which actually interferes with the macerative 
action of the surrounding fluid so long as vitality is preserved at the 
average standard. The comfort and therapeutic value of a bath pre¬ 
pared and administered in approximation to this ideal can scarcely be 
overestimated. Were it not for the difficulties with which it is attended, 
so far as relates to many portions of the surface of the body, it would 
be possible with this single therapeutic measure to rob the exudative 
affections of the skin of a great many of their formidable features. 

In acute inflammations of the skin, the application of pure water, 
even when of proper temperature, is often prejudicial to the integu¬ 
ment, and soap-and-water washings may prove quite harmful. The 
greatest caution must be exercised in giving instruction to patients as 
to the washing of the inflamed skin. 

Water for external application, as in the bath, is medicated by the 
addition of a large number of substances, such as marine salt, sodic 
and potassic salts, alum, tannin, the mineral acids, mucilages, gelatin, 
bran, and the orange leaf. 

The alkaline bath, made by adding the bicarbonate or the biborate 
of sodium to water uf the proper temperature in the proportion of 
12 ounces of either salt to 30 gallons, is usually grateful to the inflamed 
skin, pulphur baths are best prepared by adding an ounce of Vlem- 
mckx s solution 1 to the above-mentioned quantity of water. 

1 The formula is: 

R.—Calcis, g ss . 

Sulphur, sublim. A ’• 

Aq. dest. • nonl ™ 

Coque ad 3vj [200] deinde filtra. ’ 320 M> 

Sig. “ Vleminckx’s Solution.” 


GENERAL THERAPEUTICS . 


81 


When employed as a lotion, water is made to produce a sedative 
effect by the addition of opium, belladonna, glycerin, carbolic acid, 
hydrocyanic acid, zinc, bismuth, mtrcury, lead, and the alkaline bicar¬ 
bonates with the sodic bi borate. It is rendered stimulating by the 
admixture of alcohol, most of the acids and alkalies in stronger solution 
than iu the soothing or sedative lotions, and also by a large number of 
substauces which operate upon the surface either mechanically or chem¬ 
ically. Water is also rendered astringent when tannin, lead, and 
similar medicaments are dissolved in it; and by its union in various 
degrees with soaps and alkalies a solvent effect is produced, either upon 
the cuticle itself or upon pathological or foreign products upon its 
surface. 

“ Over-fatty,” or “ superfatted ” soaps, both soda and potash soaps, 
are neither alkaline nor neutral in reaction, but contain a slight excess 
of unsaponified fat. They are exceedingly mild in their detersive 
action upon the skin, though the lather produced in their use is not so 
abundant as that with the alkaline soaps. These are usually proprie¬ 
tary articles. 

Medicated Soaps, containing carbolic acid, glycerin, tar, sulphur, 
and various oils, are sold in the shops, but they usually contain so small 
a portion of the individual medicament from which each is named that 
they are practically worthless except for purposes of ablution. The 
author had such prepared under cold pressure, so as to contain medic¬ 
inal substances in therapeutic proportions, but, after experimentation, 
concluded that other forms of administration are preferable. 

Fatty and Oily Substances are applied to the skin either directly 
by pouring, or by friction, or by the mediation of compresses, bandages, 
etc., which are saturated or are spread with the material to be applied. 
The oils may be used for either nutritive, soothing, or stimulating 
effects. To the first and second classes belong cod-liver, lard, olive, 
almond, linseed, neat’s-foot, castor, and similar oils; to the third class 
belong the oil of tar, of cade, of white birch, of the cashew nut, and 
of juniper. 

Fatty substances are also applied in the form of ointments or pomades. 
They are compounded with various medicinal substances, according to 
the requirements of each case, such as the salts of mercury, zinc, cop¬ 
per, lead, and sulphur; pyrogallol, chrysarobin, carbolic and hyposul- 
phurous acids; tar, camphor, iodoform, balsam of Peru, hydrate of 
chloral, and the extracts of opium, belladonna, etc. 

The products of petroleum refinement, known as Vaselin and Cos- 
molin, though not true fats, are increasingly employed for similar 
purposes, and continue to enjoy high favor in America and in Europe. 
They are particularly useful as bases for ointments for application to 
the hairy portions of the body, such as the scalp, where more consistent 
salves paste the hairs to the surface in an unsightly mass. 

Glycerin, even the best, when applied in its purity to the skin is 
usually irritating. It is, however, exceedingly useful when diluted or 


82 


DISEASES OF THE SKIN. 


made a component part of lotions and ointments. "W hen combined 
with starch it makes, in different proportions, a series of combinations 
known as glycerols, or glycerolates. These combinations are pasty, 
semi-solid substances which are capable of varied medication, as in the 
glycerol of the subacetate of lead. They are useful chiefly as pro- 
tectives of the skin-surface. Glycerin, used in a fluid soap, is an 
exceedingly valuable agent when a milder effect is desired than that 
produced by the spirit of soap described above. The Vienna prepara¬ 
tion known as Sarg’s fluid soap, is an admirable substitute of this sort 
when a soft shampoo is required for the scalp. 


Glyco-gelatins contain equal parts of glycerin, gelatin, and water 
when hard; with three parts of gelatin, five of glycerin, and nine of 
water for the softer preparations. To either of these may be added 
5 to 10 per cent, of zinc oxid, chrysarobin, or the compounds of lead, 
mercury, and other medicaments as needed. The solid glyco-gelatins 
require to be dissolved before application. 


Pastes employed for local application in diseases of the skin have 
greatly been perfected by Lassar and Unna. 1 

These pastes are valuable especially in the exudative affections, where 
salves are often either not well tolerated or actually prove irritatiug to 
the skiu. The pastes, when applied to such surfaces, form a protective 
and adhesive dressing, which may be medicated as desired. One of 
the best and most serviceable pastes is the following modification of 
Lassar’s paste: 


R. —Zinci oxidi, 1 „.. 

Talc., T 

Acid, salicylic., gr. x ; 

Yaselin., Jss ; 


aa 8 

166 

161 M. 


To this base may be added various remedies in desired proportions. 

Other pastes are prepared with kaolin [terra alba, or Armenian bole 
of red color, when it is desirable to have the application resemble the 
color of the skin], gum, lead, dextrin, glycerin, and other substances. 
Formulae for each are here appended: 

Kaolin in a pure state, with equal parts of vaselin or glycerin, or 
with almond, olive, or linseed oil, in the proportion of two to one, is 
readily applied in a thin layer over the skin. When it is desired to 
add the oxid of zinc, or the plumbic acetate, the kaolin and oil or 
glycerin are first carefully mixed in order to prevent the formation of 
an insoluble compound, e.g.: 

R—Kaolini pur., ■) 

01 lini [vel glycerini], |aa 30 parts. 

Zinci oxidi, 1 

Liq. plumb, subcetat , \ ^ 20—M. 

For making lead pastes, litharge is boiled with twice the quantity 
of vinegar until the latter has evaporated and there is left a damp but 
drying paste, which may be, on occasion, remoistened with a small 
quantity of vinegar, e.g.; 


1 Monatsh. f. prakt. Derm., February and March, 1884. 



GENERAL THERAPEUTICS. 


83 


R.—Lithargyr. subt. pulv., ^jss; 

Aceti, £ ijss; 

Coque usque ad consistent, pastse: deinde adde ol. lini [v. glycerini, 
10.—M. 


50 i 
80 

ol. olivse]. 


In the two forms of pastes above described; the adhesive and desic¬ 
cative qualities are obtained from the main ingredients, but in those 
resulting from combinations of gum, starch, and dextrin, these results 
are for the most part obtained by the addition of other ingredients, such 
as sulphur, zinc, etc. A good basis, semi-solid, rapidly drying, and 
fixing its ingredients well upon the surface, is the following: 


R —Amyli oryzse, 9 ijss; 

Glycerini, £ss; 

Aq. dest, 3 ss; 

Coque ad remanant, :§ss 15). 


3 

2 

15 


M. 


For convenience, the solid substances are mixed at once with the 
glycerin, starch, and water, and then heated together. 


R.—Zincioxid , 

Acid, salicylic., 
Amyli oryzse, \ 
Glycerini, J 
Aq. dest., 

Coque ad., £ivss(140). 


Ijss; 

3ss; 
aa 3 iij; 
3 ijss; 


50 

2 | 

15 
751 


For a sulphur paste: 


R.—Sulphur, prsecipit., 

Ijss: 

Calc, carb., 

7t ss; 

Zinc, oxid., 

|ss: 

Amyl, oryzse, 

jpj; 

Glycerini, 

3 ss ; 

Aq dest., 

Coque ad., £iv (120). 

1 ijss 


40 

O 


15 

20 

75 


To make use of dextrin, the official pulverized article is selected, 
and a simple paste of this forms a good drying base. An added half¬ 
weight of glycerin is required if powders are also combined with the 
paste— e.g.: 


R.—Zinc, oxid., 

Dextrin., ) 

Aq dest., / 

Glycerin., 

Sulphur sublim. [vel sod. 
sulpho-ichthyol]., 

Coq. 


3j ss ; 

40 

aa £ss; 

20 

3jss; 

40 

} 3ss; 

2 


A mixture of dextrin and lead is thus prepared: 


R.—Lithargyr., ,|j; 30| 

Acet., Ijss; 50| 

Coque ad remanent., 50. 

Adde dextrin., 1 

Aq., . \ aa ^ss; 15[ 

Glycerin., j 

Coque. 

If too consistent, these pastes are made to spread easily by the addi¬ 
tion of a few drops of hot water. Such water is not required in 
making the paste if another fluid be one of the constituents, as 





84 


DISEASES OF THE SKIN. 


B. —Dextrin, 

Glycerin., 

Liq. plumb, subace tat 
Coq. ft. pasta. 


J 


z y ss ; 


10| M. 


For the gum pastes, gum arabic is used in the proportion of one part 
of mucilage and glycerin to two of the powder selected, mixed with¬ 
out heat— e.g. : 


B-—Zinc, oxid., 

3jss; 

40 

Hydrarg oxid rub., 

3 ss; 

2 

Mucilag. acac., \ 
Glycerin., J 

aa 3; ss; 

20 

B.—Cret. prseparat., \ 

Sulphur, sublim., J 

aa 3 ss; 

2 

Picis liquid., 

Jijl 

8 ' 

20 

Amyli, 

gas: 

Mucilag acac., \ 
Glycerin., J 

aii % ss; 

15 i 

B.—Acid, salicylic., 

3 ss ; 

20 

Glycerin., 

3 ss ; 

20 

Mucilag. acac , 

3j; 

30 

01 . ricini, 

Z iks; 

10 


M. 


M. 


M. 


The following details are to be noted respecting the availability of 
these pastes for different ingredients: Lead is best used as an acetate, 
either in a simple paste or with dextrin, the carbonate, oleate, and 
iodid combining well with both. Zinc oxid combines well with kaolin, 
lead, starch, dextrin, and gum. Sulphur combines well with kaolin, 
lead, starch, dextrin, and gum. Sulphur combines well with the three 
last named, poorly with kaolin, and not at all with lead. Ichthyol 
suits well with all save the gum pastes. Naphthol, calomel, corrosive 
sublimate, red and white precipitate, carbolic acid, chloral hydrate, 
camphor, and salicylic acid can be incorporated with all, the last 
named in smaller proportion with gum paste. Tar is better united 
with starch, dextrin, and gum, than with the others. Iodin and iodo¬ 
form naturally do not suit well with the starch and dextrin pastes. 
Chrysarobin and pryogallol are united with kaolin and gum pastes 
and should not be added to them. Fatty and soapy substances, if com¬ 
mingled in large amounts with these pastes, injure their special prop¬ 
erties. 

Gelatin and Glycerin Pastes, or varnishes, are useful for pro¬ 
tecting a surface and excluding the air. They are made in varying 
proportions of glycerin, gelatin, zinc oxid, and water. When cold 
they are solid, but when melted in a water-bath can be painted readily 
over a surface upon which on cooling they form an adherent protective 
coating. Before the paste has hardened on the skin it is well to pat it 
with cotton, or to lay over it a thin piece of gauze or muslin to form 
an additional protection and to prevent the paste from sticking to the 
clothing. A fairly hard paste is made by the combination of zinc oxid 
and gelatin each twenty parts, of glycerin and water each thirty parts. 
To this as a base may be added white precipitate, sulphur, chrysaro¬ 
bin, iodoform, or other antiseptics. Some drugs, as salicylic acid, 




GENERAL THERAPEUTICS. 


85 


resorcin, naphthol, and carbolic acid, tend to destroy the coherence of 
the gelatin. Fox says this obstacle may be removed by adding to the 
paste 5 or 10 per cent, of fresh lard. 

Instead of gelatin, tragacanth may be used, as in Pick’s varnish, 
which is made as follows: 

R •—Tragacanth, ; 5 

Glycerin., 3ss; 2 

Distilled water, ^ iij; 93 

This is applied without heating and quickly dries in the skin. 
An improvement on this varnish is Elliott’s bassorin paste, which 
keeps better than the former. The formula is as follows: 


R. —Bassorin, 

3j ss ; 

4^ 

Dextrin, 


25 

Glycerin., 

7) b ss ; 

10 

Water to make 

3 m'; 

100 


This should be kept in a tightly closed jar, as it dries rapidly on 
exposure to the air. Like the other pastes, it not only serves as a 
protective coating, but also as a base for the application of other rem¬ 
edies. 

Powders are mechanically dusted over the surface of the skin for 
the purpose of protecting it, and occasionally, also, to produce an 
astringent or anti-pruritic effect. To be serviceable, they should gener¬ 
ally be rendered impalpable by sifting them carefully through a fine 
silk bolting-cloth. They are composed of starch, talc, magnesia, lyco¬ 
podium, bismuth, boric acid, camphor, tannin, oxid of zinc, iodoform, 
salicylic acid, and similar substances. The articles sold by grocers 
as “Oswego gloss starch” and “corn starch farina” are usually 
much more finely bolted than the dusting-powders extemporaneously 
prepared by chemists. All starchy substances are open to the objec¬ 
tion of forming little pasty rolls or “ cakes,” when wetted with serum 
or with sweat. Lycopodium, which is seen under the microscope to 
consist of irregularly shaped globular, pollen sporules, never behaves 
in this way, and is, for that reason, deservedly popular. Stearate of 
zinc is excellent for similar reasons, and when dusted on the surface 
forms a dressing impervious to moisture. 

Faithful, of Australia, has suggested the preparation of medicated 
powders by first dissolving them in alcohol, ether, or chloroform. The 
solution is then mixed with starch or with French chalk. Evaporation 
of the menstruum is conducted without artificial heat, and a fine medi¬ 
cated starch or a chalk powder results. 

For absorbent purposes Grundler 1 has shown that by far the most 
effective powder is magnesium carbonate. 

Plasters are employed when it is desired to exert a more or less 
continuous effect upon the skin, and are thus necessarily consistent 
and desirable. The resin plasters are less useful in skin diseases, be¬ 
cause more irritating than the lead plasters. Unna’s plaster-mulls are 


i Monat. f. prak. Derm., 1888, No. 20. 




86 


DISEASES OF THE SKIN. 


described below. The mercurial plasters are useful, especially in 
syphilitic lesions of the skin. 

A valuable addition to the list of methods for applying medicated 
ointments to the skin has been devised by Unna. His Salve-muslins 
or salve-mulls are strips or bandages of muslin thoroughly impregnated 
and thickly spread with ointments medicated by almost every desirable 
substance, from the oxid of zinc to tar, thymol, salicylic acid, and 
mercury. They are elegantly made, and, when imported to America, 
are surrounded by impermeable-tissue, so that they are quite fresh and 
sweet when used. They are efficacious, and, as a rule, well liked by 
patients. The chief objection to their general employment is the 
expense of their importation. They are available in skin diseases of 
the exudative class affecting the extremities, but should be avoided 
when not recently prepared. 

Unna’s Plaster-mulls seem to be less useful. They are plasters 
thinly spread on gutta-percha cloth, and manufactured with a wide 
range of medicinal constituents. They serve a good purpose in the 
protection of parts of the skin exposed to friction. 

Salve-pencils (stili unguentes) and Paste-pencils (stili dilubiles), 
the latter uuprovided with fat and soluble when moist; the former 
insoluble in water, and compounded of fatty substances, are pencil¬ 
sized crayons made with wax, gum, and starch, for application to 
limited areas of the skin. The several mercurials, arsenous acid, 
coca'in, salicylic acid, and other medicaments for topical use in this 
way may be applied to the surface. 

Poultices are not often ordered in the management of diseases of 
the skin, except for the purpose of softening crusts with a view to their 
removal. They are made, both warm and cold, with linseed meal, 
potato-starch, bread and milk, oatmeal, and corn-meal. These appli¬ 
cations are objectionable in all conditions where a macerative effect of 
the epidermis is produced; and also where micro-organisms may find a 
genial culture-field in the mass of the poultice. Poultices, in any 
needful case, may be made antiseptic by the addition of the mercuric 
bichlorid. 

Lanolin, or wool-fat, was first introduced as a salve-base by Lie- 
breich, of Berlin. It is a peculiar substance obtained from keratinic 
tissues, and contains cholesterin fat instead of glycerin, with but 30 
per cent, of water. It has a bright yellowish color, a distinct odor of 
the sheep, and is neutral; never, when pure, is it acid in reaction. 
In 1886 Prof. Liebreich called attention to a lanolinum purissimum 
which, being free from cholesterin compounds, required no fatty addi¬ 
tion. 

This substance now seems to have outlived the period both of extrav¬ 
agant praise and denunciation. It is readily absorbed from the surface 
of the skin, and, either pure or medicated, may be regarded simply as 
a useful addition to the bases of ointments for employment upon the 
skin. 


GENERAL THERAPEUTICS. 


87 


Oleates of zinc, mercury, copper, lead, and other metals have been 
employed with advantage in the topical treatment of disorders of the 
skin. Of these, the oleate of mercury and of lead are decidedly the 
most valuable. The latter is represented by Hebra’s white diachylon 
ointment. The oleate of mercury is serviceable in syphilitic, parasitic, 
and other disorders. 

Collodion and Traumaticin are employed for the purpose of 
applying a remedy to the skin, and at the same time for protecting or 
contracting the surface to which the application is made. Traumaticin 
is the name given to a solution of gutta-percha in chloroform, in the 
proportion of 10 per cent. In this way bismuth, cantharides, sulphur, 
chrysarobin, oxid of zinc, white precipitate, iodin, and other substances 
may with advantage be applied to the surface, and the action of each 
definitely limited to the margins of a single patch of disease. 

Tar in its several varieties, crude and distilled, together with its 
derivatives, occupies an important place among efficient topical agents. 
In general, it seems to exert upon the epidermis a local influence, 
which extends more deeply as the remedy is continuously applied. At 
times, both irritative and inflammatory effects are thus induced, and 
even systemic intoxication when absorption from the skin occurs. Pix 
liquida, or the oleum picis, is the favorite article of this group with 
most American physicians ; but the oleum cadini, or oil of juniper, and 
the oleum rusci, or oil of birch, are rather more generally employed 
by experts. The last-named, found in purity and abundance and to 
be had at a low price in American markets, is recommended above the 
others. In Vienna the distilled oil is preferred, but there is good 
reason to believe that the crude oil is decidedly more efficacious. 

The skill of a physician intrusted with the management of a disease 
of the skin might almost be measured by his success in the use of tar. 
He who has not had experience in its employment is urgently advised 
to select one member of the tar family and learn thoroughly how to 
apply that, singly and in combination, either as a lotion or in salve. 
Properly employed, it will favor involution of lesions, lessening hyper- 
aemia, infiltration, scaling, and discharge. It serves admirably as an 
antipruritic. As suggested above, it may, however, produce severe 
inflammation of the skin. 

To produce the benign or emollient effects of tar, it is best mixed 
with some soothing or astringent powder, and with this end in view 
nothing is better than chalk. Spender’s hints 1 for making such an 
ointment are admirable. Finely levigated chalk is strewed into the 
melted lard in a stone jar, the whole being stirred until it is cold. 
Then at first the smallest quantity of tar sufficient to make a brownish 
smear of color is added to the quantity of salve employed for use. 
This color can be successively deepened at will. Auspitz advises the 
use of the tars in a pure state, applied in very small quantities with a 
strong bristle-brush and well rubbed in. In combination with one of 


i Practitioner, June, 1883, p. 402. 


88 


DISEASES OF THE SKIN. 


the most valuable of all substances for topical use in cutaneous thera¬ 
peutics, viz., sulphur, tar enjoys a special reputation. The Wilkinson 
salve modified ( q . r.) represents such a combination. 

Ichtkyol, fish-oil, introduced to the profession by Unna, is the 
distillate of a bituminous and sulphurous deposit of petrified fishes 
and marine fossils found in the Tyrol. Its chemical formula is 
C 26 H 36 S 3 Na 2 0 6 . It has a tarry appearance, odor, and consistency. It 
is soluble in water, partly so in ether and alcohol, and can be incor¬ 
porated in any desired proportion with fat, vaselin, and lanolin. It 
has been used both pure and diluted; and several proprietary articles 
(plasters, soaps, salves, and medicated cotton) are sold in the market. 
It has been used both in America and in Europe in cases of leprosy, 
pruritus, acne, sycosis, eczema, psoriasis, and a number of other cuta¬ 
neous disorders. 1 It is used in solutions and salves of from 10 to 20 
per cent, strength. As before stated, it is also administered internally, 
more particularly in the management of rheumatism, in doses of from 
fifteen to twenty drops. It does not seem to have a disturbing effect 
upon the stomach. 

Unpleasant results have been reported as following its application 
in a single instance (Sinclair). A four months’ old infant sank into a 
state of stupor two hours after its head and limbs were smeared with 
a salve composed of one part of ichthyol to five of vaselin. 

A group of substances which occupy a therapeutic position inferior 
to the tars, but which serve an important end in the management of 
cutaneous diseases by the production of similar effects, are carbolic 
acid, creosote, salicylic acid, benzol, naphtol, iodol, chrysarobin, pyro- 
gallol, resorcin, and jequirity. 

Resorcin in ointments of the strength of from 5 to 20 per cent, 
serves as an antipruritic and alterative. Stelwagon reports an anodyne 
effect following its use. The same experimenter has modified Ihle’s 
formula by adding 1 drachm (4.) of resorcin to 1 to 2 drachms (4.-8.) 
of castor-oil, 5 minims (0.33) of Peruvian balsam and 4 ounces'(128.) 
of alcohol, for use in alopecia and seborrhcea of the scalp. It is a 
valuable parasiticide in lotions of the strength of from 5 to 10 per 
cent. 

Naphtol, or /3-naphtol, as it is termed chemically, first introduced 
by Kaposi, is chiefly valuable in scabies, but has also been used in the 
management of eczema, psoriasis, and other exudative affections. Van 
Harlingen 2 has found it to answer well in seborrhoea of the scalp. 
Neisser has described renal disorders as resulting from its use in chil¬ 
dren, but MM.Josias and Nocard 3 report that in ordinary medicinal 
doses it is harmless. The fact that the naphtol preparations are odor¬ 
less and do not stain the skin is to be set down in their favor. 


1 See Baumann and Schotten: Monatsh. f. Prakt. Derm., 1883. Unna • same iournal 1889 • r»pnt 
med. Zeit., 1883 Samml klin Vort 1885; Lorenz: Dent. med. WoSh. lsS^Stelwagon an 
fard: Journ. of Cut. and Ven. Dis.; Zeisler: Chicago Med. Journ. and Exam. 1886. 

Amer. Journ. of the Med. Sci., Oct. 1883. 3 Ann. de Derm, et de Syph., May, 1885. 


GENERAL THERAPEUTICS. 


89 


Jequirity (Abriis precatorius), employed by ophthalmologists for 
the purpose of inducing artificial inflammation of the conjunctiva, has 
been used by Dr. Shoemaker 1 in the management of lupoid and other 
ulcers. One part of the cleansed, decorticated, and bruised grains, 
macerated for twenty-four hours, and reduced by rubbing in a mortar to 
a smooth paste, was added to sufficient water to make four parts. This 
emulsion was used for local application. 

Sulphur, popularly employed chiefly as a laxative or for the local 
treatment of scabies, has also a deserved reputation in cutaneous ther¬ 
apeutics, as an external agent in a wide range of non-parasitic disorders. 
Hebra once regarded it as valueless in eczema, but his opinions on this 
point are not now generally accepted. The precipitated sulphur is to 
be preferred to the other compounds of the pharmacopoeia. It may 
mechanically be incorporated with salve-bases or chemically combined 
with vaselin and other petroleum products, a process by which, as 
experiments have shown, its therapeutic value is not increased. It is 
also applied after mechanical union with various substances as a lotion. 
It is irritating to the acutely inflamed skin, but much better tolerated 
than the tars in conditions of subacute or chronic exudation. 

Mercury and its compounds are of value in the local treatment of 
many disorders of the skin, syphilitic and non-syphilitic. Corrosive 
sublimate as a parasiticide is of great importance in the treatment of sev¬ 
eral cutaneous disorders due to the presence of microorganisms, as, for 
example, lupus vulgaris. Calomel, the oxids, iodids, and the ammonio- 
chlorid are chiefly used in the form of ointments, but the “ black 
wash,” prepared with the mild chlorid, is of great value in eczema. 
Piffard 2 called attention to the fact that the official ointment of white 
precipitate is made with pure lard instead of as formerly with lard 
and wax; and to this change, tending to hasten the absorption of the 
mercurial, he attributes some late failures with this admirable salve. 
Disagreeable dermatitis followed by scaling has been reported by Green 3 
to follow its use in the strength of 40 grains (2.66) to the ounce (32.). 

Chloral-camphor and Phenol-camphor have value chiefly as 
antipruritics. The former is obtained by rubbing together the hydrate 
of chloral and gum-camphor (Bulkley) until they form a clear liquid 
of pungent odor. Phenol-camphor is made by gradually adding cam¬ 
phor to melted crystals of carbolic acid, a colorless liquid resulting 
having the fragrant odor of camphor without that of the acid. It is 
a useful local anaesthetic agent, being insoluble in water, but freely 
soluble in chloroform, ether, and alcohol. 

Many Agents are employed upon the surface of the integument to 
produce in various degrees a Caustic or Destructive effect. Among 
these may be named the thermo-cautery (Paquelin-knife), galvano- 


1 Lancet, Aug. 1884, p.185. 

2 Journ. of Cutan. and Ven. Dis., Oct. 1886. 


Brit. Med. Journ., 1865. 


90 


DISEASES OF THE SKIN. 


caustic apparatus, the mineral acids and alkalies, ethylate of sodium, 
arseuic, chlorid of zinc, several mercurial compounds, acid nitrate of 
mercury, bichlorid of mercury, chlorid of antimony, sulphate of cop¬ 
per, and nitrate of silver. Several of these substances in weak solution 
are employed as milder agents for the production of irritative, or even 
various inflammatory, effects. To the latter class should be added 
iodin in tincture, chloroform, tartar emetic, croton oil, and cantharides. 

These destructive effects are of advantage in the treatment of disor¬ 
ders of the integument due to parasites, either animal or vegetable. 
Of those employed for this purpose, and not mentioned above, may be 
named petroleum and stapliysagria, for the destruction of lice; sulphur, 
styrax, and balsam of Peru, for the destruction of acari; and sulphur 
and its compounds and a number of derivatives from tar for the 
destruction of vegetable parasites. 

Counter-irritation over the Vaso-motor Centres, as recom¬ 
mended by Crocker, is an efficient means of unseating fixed and obsti¬ 
nate cutaneous disorders. It may be produced by the action of 
sinapisms, blisters, or caustics over the region selected for such irrita¬ 
tion. 

Hypodermatic Injection is a method of introducing various sub¬ 
stances within the body that is often not merely efficacious, but neces¬ 
sitated by the failure of the digestive processes. Such medicaments 
as arsenic, mercury, and pilocarpin are successfully employed in this 
way; and the widely known results of the injection of Tuberculin, 
originally devised by the eminent Robert Koch for lupus vulgaris and 
other forms of tuberculosis, need only be mentioned in this counection. 

Electrolysis is an agent of the greatest value in the treatment of 
a large number of cutaneous affections, such as hypertrichosis, telan¬ 
giectases, molluscous tumors, warts, etc. It is accomplished by the aid 
of the galvanic battery in the manner described in this work in the 
pages devoted to the first of the disorders named. 

The Minor and other Surgical Operations required in the man¬ 
agement of some affections of the skin are detailed in the treatises 
devoted to that subject. Among such procedures may be named skiu- 
grafting, both by the methods of Reverdin and Thiersch, and the 
several devices of plastic surgery. Strictly dermatological procedures 
to which resort must often be made are: epilation in hyphogenous 
sycosis and other affections; massage, especially by the massering-ball; 
the operations on the face, especially in acne, when opening small ab¬ 
scesses, removing comedones and incising papules; and multiple scari¬ 
fication as in telangiectases and other lesions. 

A variety of Surgical and other Appliances are found useful as 
adjuvants in the treatment of skin diseases. They may be employed 
to support, protect, or compress the surface, or merely to aid in the 
retention of dressings or external medicaments. Thus, the ordinary 


GENERAL THERAPEUTICS. 


91 


roller-bandage is applicable to many portions of the body; the suspen¬ 
der, or suspensory bag, to the scrotum; elastic or inelastic stockings to 
the feet and legs; kid, rubber, and thread gloves to the feet and fingers; 
and various skull-caps, face-masks, and mittens are employed in the 
case of infants and children to protect affected surfaces from the 
dangers of scratching. 

Fig. 23. 



Irido-platinum needle. 


Fig. 24. 








Milium needle. 
Fig. 25. 


Scarifying-spud. 



Epilating-forceps. 


Fig. 27. 



Piffard’s grappling-forceps. 


Fig. 28. 



Piffard’s cutisector. 
Fig. 29. 



Dermal curettes. 




































92 


DISEASES OF THE SKIN. 


Fig. 31. 



HEMANN -CO-NY 


Hess’s glass pleximeter. For observing the skin under pressure. 


Fig. 32. 



Piffard’s modification of Unna’s comedo-extractor. 


Fig. 33. 

Keyes’s cutaneous punch. 


Fig. 34. 



Hyde’s massering-ball. 


It is an axiom in dermatology that a salve is worth far more to the 
patient when it is spread oo muslin, and thus retained in contact with 
the integument, than when it is merely smeared or rubbed over the skin- 
surface. It is this important feature which doubtless has contributed 
so largely to the reputation of Unna’s salben-mulle , or salve-muslins. 
To secure the retention of such salve-spread muslins in contact with 
the skin-surface, the common muslin roller, which exercises more or 
less compression, is inferior to the light and more pervious cheese¬ 
cloth bandage. This is especially true when the dressing is made by 
the patient, who is, iu general, far less expert than either the trained 
nurse or the physician. 

Apart from the surgical apparatus required for ablation of tumors 
or severe operations, a number of instruments are required for the 
daily use of the dermatologist. Among these may be named : 

A set of variously sized dermal curettes. These sharp-edged spoons 
are for erasion of the surface, and should, for general use, have in each 
a fenestrum large enough to permit the escape from the floor of the 
spoon, of all collected substances. The small-sized spoons, however, 
with solid bowl and sharp edges, largely used in Vienna, are preferable 
for use, especially about the face, in many skin affections. Epilating- 
forceps with easy springs and smooth blades meeting in perfect appo¬ 
sition; a set of Piffard’s comedone-extractors, provided at each extrem¬ 
ity with a differently sized, minute, spoon-shaped and perforated bowl, 











CLASSIFICA TION. 


93 


the convex surface of which is pressed over the comedo with the orifice 
immediately over the black head of the plug. This is a great 
improvement over the old-fashioned comedo-extractor shaped like 
a watch-key, and the discomfort to the patient by its use is greatly 
reduced. A set of half-inch and four-inch lenses for examining the 
surface of the skin; needle-holders with light handles for firmly 
grasping the needles used in opening pustules, etc. The needles, some 
of them, should be flat, with a double-cutting edge, others be rounded 
neatly on an emery-wheel, and all of them very carefully disinfected 
if used more than once. Too many precautions cannot be taken in 
the practice of dermatology, with respect to the disinfection of all instru¬ 
ments made to penetrate the skin. Probes, exploring-needles, fine 
dressing-forceps, delicate straight and curved scissors, and other instru¬ 
ments from the ordinary pocket-case of the surgeon, are indispensable. 
The instruments required for use in connection with the galvanic bat¬ 
tery are enumerated in the chapter on Hypertrichosis. 


VII. CLASSIFICATION. 

The numerous attempts which have been made to classify diseases 
of the skin according to their nature and relations have been in 
response to the generally recognized demand for a systematic arrange¬ 
ment of all scientific facts. As regards dermatology, not only have 
these attempts been numerous and based upon different principles, but 
the results which they have accomplished have also been in the highest 
degree divergent. No classification yet devised has secured general 
acceptance. While it is certain that no one system of classification 
has been perfect and that each has exhibited defects, it is equally true 
that of the large number each has possessed some merit of its own. 
No perfectly satisfactory classification of cutaneous diseases can be 
made until the knowledge of diseases of the skin has been greatly 
enlarged. 

One of the most acceptable of the systems thus far proposed is that 
of Hebra. By it cutaneous disorders are arranged in the following 
nine classes: 

Class 1. Disorders of Secretion. 

Class 2. Hyperemias. 

Class 3. Exudations. 

Class 4. Hemorrhages. 

Class 5. Hypertrophies. 

Class 6. Atrophies. 

Class 7. New Growths. 

Class 8 . Neuroses. 

Class 9. Parasites. 



94 


DISEASES OF THE SKIN. 


Since this classification was devised by Hebra, none has been pro¬ 
posed which compares in ingenuity with the arrangement made by 
Auspitz. The principle of this classification is to place together those 
diseases and groups of diseases which present a clinical unity, the gen¬ 
eral pathological process being the predominant characteristic for selec¬ 
tion; individual characteristics, such as symptoms, localization, ana¬ 
tomical peculiarities, etc., being only brought thus predominantly 
forward when coinciding with the real nature of the class, the group, 
or the skin disease in question. 1 Auspitz’s nine classes are : 

1. Simple Inflammatory Dermatoses; 2. Angioneurotic Dermatoses; 
3. Neuritic Dermatoses; 4. Stasic Dermatoses; 5. Hemorrhagic Der¬ 
matoses ; 6. Idioneuroses; 7. Epidermidoses; 8. Chorio-Blastoses; 9. 
Dermatomycoses. 

Under these classes, by the aid of divisions and subdivisions, an elab¬ 
orate scheme is presented, which embraces fully not only all cutaneous 
diseases, but also all pathological processes recognized in the skin. 
This system, accepted with modifications by Hans Hebra, 2 has unques¬ 
tionably been followed by a greater advance in the nosology of cuta¬ 
neous medicine than any of those proposed since that first offered by 
Hebra. 3 

Auspitz’s classification, however, is open to various objections on 
the part of the student of dermatology. It is elaborated to the extent 
of setting the names of some diseases in more than one family, and hence 
is confusing to the beginner. It is better adapted to the needs of the 
expert than of the young student, for it introduces to the study rather 
of morbid processes in the skin than of the complexus of those pro¬ 
cesses which are recognized in disease. 

Whether the principle of classification be anatomical, etiological, or 
pathological; whether it be based on the processes actually occurring 
in the skin, or on those deeper factors and forces which operate cen- 
trifugally upon the skin and on which that organ depends for all its 
functions and even its existence; whether it proceed etiologically from 
causes which are immediate or those which are remote, it is easy to 
see that, as knowledge in each of these directions enlarges, the exact 
position of any one disease in any given classification must be rendered 
insecure. Never was this observation more suggestive than at this 
day, when the pathogeny of numerous skin disorders is revealed in the 
light thrown on the subject by the discovery of new and hitherto 
unknown inferior organisms. 

Indeed, to this last cause, awakening grave doubts as to the precision 
of much that was once esteemed fact, may be attributed the declining 
interest in the general subject of classification of diseases of the skin. 
The earnest discussion of this theme has practically been deferred by 
common consent to a date when the questions thus suggested can 
more satisfactorily be answered. Several recent writers have actually 

1 System d. Hautkrankheiten. Wien, 1881. 

2 Die Krankh. Veranderung. der Haut. Braunschweig, 1884. 

3 An exceedingly ingenious and comprehensive scheme of classification of diseases of the skin, 
embracing most of the principles upon which the best of previous classifications were based, was 
presented by Dr. E. B. Bronson, of New York, at the meeting of the American Dermatological 
Association, in August, 1887. 


CLASSIFICATION. 


95 


contented themselves with an alphabetical arrangement of the names 
of skin diseases, as an order useful simply for reference. 

The classification recognized in the arrangement of subjects in this 
work is practically that adopted by the American Dermatological Asso¬ 
ciation, August 29, 1878, and revised by the same body August 28, 
1884. It is a modification of the scheme first proposed by Hebra. 
Pending a decision on many points, the Association has for a time 
employed a provisional schedule with an alphabetical list of all 
cutaneous affections. Viewing the rapid changes made annually in the 
knowledge of many subjects connected with diseases of the skin, it is 
generally conceded that at this time it is proper to defer assigning a defi¬ 
nite position in pathology to a large number of recognized affections. 

While, however, scientific men are cautious in committing them¬ 
selves to definite conclusions with relation to this subject, it is exceed¬ 
ingly undesirable to relegate the student of dermatology and the 
practitioner who for the first time begins its systematic investigation, 
to a list of names in alphabetical arrangement. The latest classifica¬ 
tion of skin diseases proposed by the recognized experts of dermatology 
in America has been, therefore, accepted in a modified form for the 
purposes of this treatise. It is not claimed to be either complete or 
without defects; however, it stands to-day as the most convenient 
nosological scheme available for a text-book of cutaneous medicine, 
and will doubtless be revised in the future as occasion shall require. 


Classification of Diseases of the Skin adopted by the American 
Dermatological Association. 


Class I Disorders of the Glands. 

1. Of the Sweat-glands. 

Hyperidrosis. 

Sudamen. 

Anidrosis. 

Broinidrosis 

Chromidrosis. 

Uridrosis. 

2. Of the Sebaceous Glands. 

Seborrhea: 

a. oleosa. 

b. sicca 
Comedo. 

Cyst: 

а. Milium. 

б. Steatoma. 

Asteatosis. 

Class II. Inflammations. 

Exanthemata. 

Erythema simplex. 

Erythema multiforme: 

a. papulosum. 

b. bullosum. 

c. nodosum. 

Urticaria. 

pigmentosa. 

Dermatitis i 1 
a. traumatica. 


b. venenata. 

c. calorica. 

d. medicamentosa. 

e. gangrenosa. 

Erysipelas. 

Furunculus. 

Anthrax. 

Phlegmona diffusa. 

Pustula maligna. 

Herpes simplex. 

Herpes zoster. 

Dermatitis herpetiformis. 
Psoriasis. 

Pityriasis maculata et circinata. 
Dermatitis exfoliativa. 
Pityriasis rubra. 

Lichen : 

a. planus. 

b. ruber. 

Eczema : 

a. erythematosum. 

b. papulosum. 

c. vesiculosum. 

d. madidans. 

e. pustulosum. 

f. rubrum. 

g. squamosum. 

Prurigo. 

Acne. 


Indicating affections of this class not properly included under other titles. 



96 


DISEASES OF THE SKIN. 


Class II. — Continued. 

Acne rosacea. 

Sycosis. 

Impetigo. 

Impetigo contagiosa. 

Impetigo herpetiformis. 
Ecthyma. 

Pemphigus. 

Class III. Hemorrhages. 

Purpura: 

a. simplex. 

b. hemorrhagica. 

Class IV. Hypertrophies. 

1. Of Pigment. 

Lentigo 

Chloasma. 

2. Of Epidermal and Papillary 

Layers. 

Keratosis: 

a. pilaris. 

b. senilis. 

Molluscum epitheliale. 
Callositas. 

Clavus. 

Cornu cutaneum. 

Verruca. 

Verruca necrogenica. 

Nevus pigmentosus. 

Xerosis. 

Ichthyosis. 

Onychauxis. 

Hypertrichosis. 

3. Of Connective Tissue. 

Sclerema neonatorum. 
Scleroderma. 

Morphea. 

Elephantiasis. 

Bosacea: 

a. erythematosa. 

b. hypertrophica. 

Frambesia. 


Class V. Atrophies. 

1. Of Pigment. 

Leucoderma. 

Albinismus. 

Vitiligo. 

Canities 

2. Of Hair. 

Alopecia. 

Alopecia furfuracea. 
Alopecia areata. 

Atrophia pilorum propria. 
Trichorrexis nodosa. 


3. Of Nail. 

Atrophia unguis. 

4. Of Cutis. 

Atrophia senilis. 

Atrophia maculosa et striata. 

Class VI. New Growths. 

1. Of Connective Tissue. 

Keloid. 

Cicatrix. 

Fibroma. 

Neuroma. 

Xanthoma 

2. Of Muscular Tissue. 

Myoma. 

3. Of Vessels. 

Angioma. 

Angioma pigmentosum et atrophi- 
cum. 

Angioma cavernosum. 
Lymphangioma. 

4. 

Khinoscleroma. 

Lupus erythematosus. 

Lupus vulgaris. 

Scrofuloderma. 

Syphiloderma: 

a. erythematosum. 

b. papulosum. 

c. pustulosum. 

d. tuberculosum. 

e. gummatosum. 

Lepra: 

a. tuberosa. 

b. maculosa. 

c. anesthetica. 

Carcinoma. 

Sarcoma. 

Class VII. Neuroses. 

Hyperesthesia: 

a. pruritus 

b. dermatalgia. 

Anesthesia. 

Class VIII. Parasitic Affections. 

1. Vegetable. 

Tinea favosa. 

Tinea trichophytina: 

a. circinata. 

b. tonsurans. 

c. sycosis 
Tinea versicolor. 

2. Animal. 

Scabies. 

Pediculosis capillitii. 

Pediculosis corporis. 

Pediculosis pubis. 


In the pages which follow it will be seen that many modifications of 
this classification have been necessitated by later investigations in 
cutaneous medicine. 



DISEASES OF THE SKIN. 


CLASS I. 

DISORDERS OF THE GLANDS. 

In this class of disorders are grouped all the functional disorders 
of the sweat- or coil-glands, the sweat-pores, and the sebaceous glands. 
These disorders may be betrayed in quantitative or in qualitative 
changes in the secretion, or in retention of the latter in the whole or 
in a part of the secretory apparatus. When a disease of the skin 
ceases to be purely functional in type, and is accompanied by an 
exudative process, glandular or periglandular in situation, such disease 
is properly classed with another group of affections. 


1. DISORDERS OP THE SWEAT-GLANDS. 

Hyperidrosis. 

(Gr. virep, in excess; vdop, water.) 

(Idrosis, Hydrosis, Ephidrosis, Sudatoria, Polyidrosis, 
Hyperhidrosis.) 

Statistical frequency in America, 0.265 

Hyperidrosis is an exaggerated quantitative effusion of sweat, the secretion accu¬ 
mulating in visible drops upon the surface of the skin. 

Symptoms. This condition may be physiological, as the result of 
active exertion in a medium of high temperature, or it may be patho¬ 
logical in character, and in the latter case be either general or partial. 

General sweating to a pathological extent chiefly occurs in the obese, 
but also in those who are the subjects of constitutional disease (phthisis, 
the various febrile disorders, etc.). It is the fertile source of the vari¬ 
ous forms of intertrigo, sudamina, and miliaria. Local hyperidrosis 
is the exaggerated quantitative effusion of sweat limited to certain 
definite portions of the skin, as the palms, the soles, the dorsa of the 
hands and feet, the interdigital spaces, the genitals, the axillae, and the 
temples. In such cases the secretion occurs moderately or greatly in 
excess, varying in this respect somewhat in different degrees of tem¬ 
perature, and in rapidity of the circulation; it is occasionally, but not 
commonly, accompanied by fetor. It may involve one or both sides 

7 



98 


DISEASES OF THE SKIN. 


of the body, being generally symmetrical at the extremities, and 
asymmetrical upon portions of the face. 

Its topical expression may be studied in the hands, which are con¬ 
tinually moistened, clammy, or dripping with fluid within a brief time 
after the most careful drying of the parts. In the case of a woman, 
the instincts of whose sex prompt her to take such precautions, the 
dress is constantly protected from contact with the macerated palms 
by a handkerchief or similar article which is always in readiness. The 
disadvantages thus arising in individuals of both sexes who are engaged 
as trades-people, artists, hand-workers, etc., can readily be estimated. 
In women of social position, no small complaint is made of the disa¬ 
greeable result produced after wearing kid gloves for even a short time, 
the material of which is soon soiled by its complete saturation with 
the secretion from the skin. 

With and without this local excess, occurs the hyperidrosis of the 
feet, aggravated by the mechanical force of gravity and the need of 
constant covering. The stockings and the leather of the boots, shoes, 
or gaiters are saturated with the secretion, and rapidly become subject 
to chemical alteration. There is usually an offensive odor of the 
region, originating partly in the primary fetor of the secretions them¬ 
selves, and partly in the subsequent chemical decomposition of the 
latter, rapidly progressing under the influence of the soiled and often 
stinking investments of the feet. 

The integument, constantly macerated, may become both painful and 
tender; very rarely there is vesiculation or exfoliation of patches of 
sodden epidermis. When the genitals are involved, especially in men, 
erythema and intertrigo are the frequent results. 

Etiology. The disease in rare cases may be congenital. In other 
cases it is associated in one person with disorders not apparently related 
to it. In the case of a hospital patient recently examined, a woman, 
twenty-four years of age, was affected with severe tylosis of the feet, 
from which were exfoliated extensive lamellated casts of the soles. 
She had also typical hyperidrosis of the hands. 

In no portion of the nervous system has a localized centre for excito- 
sudoral or inhibitory effects been recognized. Traumatisms, gliomata, 
gummata, scleroses, and other lesions affecting the cerebrum, medulla, 
cord, ganglia, and trunks of the sympathetic nervous system have 
been followed by local hyperidrosis, but they have all repeatedly failed 
to induce such morbid sudoral symptoms, while a fit of anger or sudden 
fright has been as conspicuously effective as any. In short, the pre¬ 
dominant influence of the nervous system, in an etiological sense, must 
be admitted here as in physiological sweating, and to the sympathetic 
branches of that system must be assigned the greater influence for most 
cases. A paralysis or paresis of the sympathetic is held to explain the 
occasional coincidence of pulmonary and cardiac disorders, with either 
general or partial excessive sweating. Compression of the sym¬ 
pathetic by adenomata, aneurysms, carcinomata, etc., has been followed 
by marked symptoms of this disorder. The disease is encountered in 
individuals of both sexes, and in all ages and degrees of general health, 
as also in those who are and those who are not careful as to cleanliness. 


DISORDERS OF THE GLANDS. 


99 


There is reason to believe that the facial asymmetrical hyperidroses 
associated with migraine, neuralgias, hemicrania, etc., are etiologically 
and pathologically distinct from the similar symmetrical affections of 
the hands and feet. The last-named disorders certainly occur with 
conspicuous frequency in young women who are the subjects of hysteria, 
chloro-anemia, some form of dysmenorrhea, or cardiac trouble. In 
one young woman under the author’s observation there was an 
habitual pulse of fifty-five to the minute without dicrotism, the patient 
being well in other respects. 

Pathology. Robinson, who examined a number of sections from the 
palm of the hand, failed to detect any abnormal feature either in the 
glands or the epithelium. The disorder is to be regarded as purely 
functional; and any anatomical changes in the coil-glands or the sweat- 
pores are probably accidents of such derangement of function. 

Treatment. When universal, hyperidrosis is to be treated internally 
by the aid of such remedies as are indicated by the general coudition 
of the patient. The various ferruginous tonics, mineral acids, arsenic, 
strychnin, quinin (the latter particularly when, as is often the case, a 
malarial affection is responsible for the disorder), and ergot, with both 
belladonna and atropin, are all of unquestioned value. Even though 
but temporarily serviceable, belladonna and atropin are well used at 
the outset of most cases. Aconite, jaborandi and pilocarpin, white 
agaric (agaricin is recommended in doses of -J- of a grain (0.011), 
repeated as required), carbolic and salicylic acids may be named as in 
the second rank. 

External treatment, wdiich is often promptly efficacious, can rarely be 
neglected in any case. The simplest method is by wiping, not washing, 
the skin surface until it is dry, and applying a dusting-powder, such as 
lycopodium, talc, salicylic acid, boric acid, bismuth, magnesia, hydrate 
of chloral (one part to five or six of starch), or starch, the chief objection 
to the latter being its tendency to form cakes or rolls after its union 
with the sweat. Alternately with either of these, or in lieu of them, 
baths or lotions may be employed, aqueous or alcoholic, and medicated 
with corrosive sublimate, tannic acid, ferric sulphate, naphtol (Kaposi), 
turpentine, zinc sulphate, alum, permanganate of potassium, or the sea 
salt now sold in packages for domestic use. Fox 1 advises a lotion con¬ 
taining one part of quinin to one hundred of alcohol. Van Harlingen 
recommends the use of juniper-tar, or carbolic-acid soap with the bath, 
as alone sufficient to relieve some cases. 

For hyperidrosis of the feet, the treatment by the method of Hebra 
has, deservedly, high repute. It consists in neatly and completely 
enveloping the entire foot, the toes separately, after thorough washing 
and drying, in strips of cotton-cloth over which is spread to the thick¬ 
ness of a common knife-blade the unguentum diachyli albi elsewhere 
described. This unguent is made by boiling one part of the best lith¬ 
arge with about four parts of pure olive oil, to which a little water is 
added while the materials are stirred together over a.slow fire. The 
parts are well bandaged, and the patient either remains subsequently 


i Journ. of Cutan. and Ven. Dis,, 1885, p. 24. 


100 


DISEASES OF THE SKIN. 


at rest or pursues his vocation, wearing over the feet shoes and stock¬ 
ings which have not previously been used. In twenty-four hours the 
feet are redressed without washing, after dry rubbing with charpie and 
a dusting-powder. This treatment is repeated daily for from ten to 
twenty days, after which a dusting-powder (boric acid) may be substi¬ 
tuted for the local dressing. There occurs a parchment-like desqua¬ 
mation of the epidermis in thick, yellowish-brown lamellae, beneath 
which is formed a new and at first tender but apparently normal epi¬ 
dermis. When the latter has lost its tenderness the feet are for the 
first time washed with water. In case of failure the routine of treat¬ 
ment is repeated as often as requisite. It is scarcely necessary to add 
that no ill effects are known to have resulted from the therapeutic 
measures adopted in checking a local hyperidrosis. 

For the diachylon salve there may be substituted tar, ichthyol, or 
naphtol ointment. Fredericq employs finely pulverized tartaric acid, 
applied at first with some caution, and always in small quantities. 
Stewart first bathes the feet in hot water and then soaks them for a few 
moments, once only, in a solution of permanganate of potassium, 4 
to 6 grains to the ounce (0.266-0.4 to 32.), after which, the plaster 
selected for use may be applied as directed above. Legoux orders 
pediluvia of tar-water twice daily, for three days, followed by painting 
of the feet with a solution of the perchlorid of iron. Morrow 1 recom¬ 
mends foot-baths in the extract of pinus Canadensis, followed by the 
application of boric acid, or of salicylic acid, mixed with lycopodium. 
Lastly, Brandon, experimenting on the permeability of the skin to 
ethers and gases, claims to have solved the problem of local treatment 
with a “ liquor anti-hidrorrho'icus,” prepared from the chloric ethers. 

Prognosis. The future of any case of hyperidrosis is uncertain. 
The disease, whether local or general, may spontaneously disappear, 
may recur, may promptly be amenable to treatment, or may prove 
obstinate to all therapy. Myrtle 2 reports the case of a male patient, 
seventy-seven years old, who sweat to death after repeated recurrences 
of severe hyperidrosis, and after temporary relief from the use of 
Fowler’s solution. 


Sudamen. 

(Lat. sudor , sweat.) 

(Miliaria Crystallina.) 

Statistical frequency in America, 0.216. 

Sudamina are discrete, superficially seated, millet-seed sized and larger, translucent 
vesicles, resembling seed-pearls. 

Symptoms. In this disorder the lesions are thickly agglomerated, 
but discrete, transitory, and translucent, pin-point-sized vesicles, 
resembling dew-drops or seed-pearls, upon the surface of the skin, 
often requiring the touch to define their real character. The lesions 

1 See his r§sum& of this subject in the Journ. of Cutan. and Ven. Dis., vol. v p 68 

2 Medical Press, February 25, 1886. 1 


DISORDERS OF THE GLANDS. 


101 


are usually limited to certain regions of the body, as the trunk, and 
here more generally upon the front and sides of the belly and in the 
iliac regions, though they may occur upon any part. Their course is 
rapid, both in evolution and involution, and their sequelae are exceed- 
ingly delicate desquamative flakes, the thin roof-wall, which originally 
covered the sweat-drops, having been lifted from the superficial stratum 
of the horny layer of the epidermis. They contain each a droplet of 
sweat, which is removed by evaporation. They are usually preceded 
by an attack of pruritus, and may follow the hyperidrosis of systemic 
debility, enteric and continued fevers, phthisis, inflammatory rheuma¬ 
tism, pneumonia, and other asthenic conditions. They may also result 
from violent exercise, the elevated temperature of the summer season, 
flannel underclothing, vapor-baths, and the application of wet hot 
cloths to the surface of the skin. 

The lesions are the result of the accumulation of sweat in high 
temperatures of the body between the most superficial layers of the 
stratum corneum, or of the medium by which the body is surrounded, 
and usually in states of adynamia. Sudamina may hence occur at all 
ages, and in both sexes. 

Three forms of sudamina have been described: (a) Sudamina alba; 
(6) sudamina rubra; and (c) sudamina crvstallina. The last-named is 
the only form to which the term sudamen is properly applied, since it 
alone of the three designates a purely functional derangement of the 
sweat-secreting apparatus. 

The first term, sudamina alba (miliaria alba), is applied to the lesions 
where there is maceration of the vesicular wall and when the contents 
become opalescent. This form is rare. The second term, sudamina 
rubra (miliaria rubra, miliaria papulosa, lichen tropicus, “ prickly 
heat”), is applied to inflammatory lesions which may accompany pro¬ 
fuse sweating. These lesions are numerous pin-point to pin-head-sized 
vesicles surrounded by a reddish halo, or papules of the same dimen¬ 
sions, or the two lesions commingled, almost invariably accompanied 
by hyperidrosis, though the latter may be absent in high temperatures. 
The marked tingling, pricking, and burning sensations by which they 
are accompanied are often in the highest degree distressing, and may 
solicit rubbing of the affected part, though the scratching elicited by 
severe pruritus is not common. Minute crusts may form after vesic¬ 
ular rupture. The attack may be mild or quite severe, and may last 
for a few days, or for a few weeks or months, the result of continuous 
aggravation or of the production of new crops of lesions after each 
recurrence of the cause. It is not rarely complicated in obese indi¬ 
viduals by all varieties of intertrigo and eczema. 

Sudamina crystallina are, however, the sole lesions which may 
properly be considered in this class of affections. These lesions are 
always free from all inflammatory symptoms, presenting a limpid, dew- 
drop-like aspect that is characteristic. 

Etiology. The disease is induced by excessive sweating, often in 
consequence of an elevated temperature; also, however, as a result of 
a systemic asthenia, as indicated above. 

Pathology. Robinson studied the anatomy of the sudamen with 


102 


DISEASES OF THE SKIN. 


special care. The contents of the vesicle are pure sweat without admix¬ 
ture of lymphoid corpuscles. The fluid collects between the laminae of 
the deeper part of the corneous layer. Robinson supposes a rupture of 
the wall of the sweat-duct, but with our present knowledge of the 
anatomy of this part of the skin we can see in his illustrations the 
obliteration merely of the sweat-pore by a sudden effusion of watery 
fluids toward the epidermis, that pass with moderate pressure through 
the wall-less sides of the pore into the spaces between the epithelial 
cells, where a chamber is readily formed. 

Diagnosis. No difficulty can arise in making a diagnosis, if the 
peculiar characters of the sudamen be kept in view. All pustular 
lesions have different contents; all bullous lesions are larger, or are 
seated on an engorged base, or they lack the limpid clearness of the 
sudamen, because, however transparent the contents, they are mostly 
covered by a thicker and less transparent roof. The halo about the 
lesions of miliary rubra, or their rosy-pink shade, will determine their 
character. In varicella the lesions are chambered. 

Treatment. Only the simplest treatment is required. Alkaline and 
bran baths may be taken, of the temperature most grateful to the skin, 
which may afterward be dusted with one or several of the dusting- 
powders, such as starch, lycopodium, or boric acid, named in the 
chapter on General Treatment of Cutaneous Diseases. The internal 
treatment is that indicated by the condition of the patient. 

Miliary Fever, u sweating sickness,” or the suette mitiaire of the 
French, is an epidemic disorder, accompanied by sweating and a cuta¬ 
neous exanthem. Pineau 1 gives a description of the disease as it 
occurred in epidemic form on the island of ORron, where, of one 
thousand patients affected, between one hundred and fifty and two 
hundred perished. The eruption appeared in the form of hyperemic 
maculae, disappearing under pressure, after which there rapidly formed 
myriads of reddish or whitish, grouped, unequally siz^d, and acumi¬ 
nate papules, rising from a whitish and macerated surface. Among 
these papules were interspersed lesions of sudamina. The region of 
the face was not spared, and the conjunctivae were occasionally affected. 
In the course of from two to four days, pin-head to bean-sized, vari¬ 
oliform but non-umbilicated pustules formed in the site of some of the 
papules, the contents of which disappeared by resorption, the final 
lesions presented being large, flat, reddish papules, the skin of the 
face particularly becoming generally reddened and swollen. In the 
course of from ten to twelve days general desquamation ensued, with 
large palmar and plantar losses. Relapses occurred in some cases with 
general redness of the surface, or with crops of reddish plaques, or yet 
again with the occurrence of furuncles. The sensations were those of 
myriads of needles thrust into the skin. 

The exanthem was accompanied in some, and unaccompanied in 
other cases, by fever. In the fatal cases death resulted from exhaus¬ 
tion. 


Archiv. gen6r. de Med., Jan. 1882, p. 25. 


DISORDERS OF THE GLANDS. 


103 


Geber and other writers, however, believe that the lesions described 
are not peculiar to any special disease, and they deny the possibility 
of an independent miliary fever. 


Hydrocystoma. 

(Hydrocystoma, Cysts of the Coil-duct.) 

Robinson, of New York, in 1893, 1 published a careful report of his 
studies in this affection, which he first described eleven years previ- 
ously, in a paper read before the American Dermatological Association. 
Reports of cases and studies of the disease have been made also by 
Hutchinson, Jackson, Jamieson, Rosenthal, Hallopeau, and others. 

Symptoms. The lesions are discrete or closely set, few or exceed- 
ingly numerous, tense, clear, shining, pin-head to pea-sized vesicles, 
never superficially seated, that is, never as near to the surface as the 
vesicles of miliaria, because the base of all hydrocystomata is to be 
found in the corium. The lesions are whitish in color, or when of 
greater age and size are dark bluish, especially at the periphery, some 
resembling boiled sago-grains. No signs of inflammation are present 
in any case. Occasionally a mild hyperemia becomes evident at the 
periphery of a single cyst. The contents are pellucid, never changing 
to a yellowish hue, and when uninjured resolve in time by desiccation, 
leaving a short-lived pigmentation. The contents of the vesicles are 
always slightly acid, never alkaline. 

Etiology. The disease occurs almost invariably in middle-aged 
women, more often in those engaged as laundresses who have been 
sweatiug freely over the wash-tub, the face beiug simultaneously ex¬ 
posed to warm vapor. There is usually aggravation of the disorder 
in summer, and either complete or partial relief in winter. Aggrava¬ 
tion has been noted at the time of the menstrual period. One of 
Hutchinson’s cases exhibited lesions on a single side of the face only. 
Robinson reports one case occurring in a young man. The few patients 
seen by the writer were all of the dispensary class, and were women 
who worked much over the washtub. 

Pathology. The epidermis, hair-sacs, and sebaceous glands were in 
all parts normal; the papillary layers having been involved only when 
the cyst approached the upper part of the corium, when, as Unna puts 
it, 11 a thin plate of flattened papillary body” is found above. Below, 
in places, the lumen of the sweat-duct is found enlarged and dis¬ 
tended with liquid and a granular material. The enlargement in the 
duct begins above the coil of the gland, and usually in the lower part 
of the corium. There is some perivascular leucocytosis in progress 
here and there in the vicinity of the vessels, but this was not a marked 
feature in any one of the several sections examined by Robinson. The 
cavities of each duct were found lined with epithelial cells. 


Journ. Cutan. and Gen.-Urin. Dis., August, 1893. 


104 


DISEASES OF THE SKIN. 


Diagnosis. The lesions of sudamina and pompholyx are readily 
distinguished by their superficial character and their situation, as they 
are rarely discovered upon the face. The vesicles of vesicular eczema 
are short-lived and inflammatory. In adenoma of the sweat-glands 
the lesions are often painful and usually firmer and larger than in 
hydrocystoma. 

Treatment. The lesions can be caused to disappear by puncturing 
each, thus permitting the escape of the imprisoned fluid. This should 
be followed with the application of dusting-powders, due care being 
had to avoid the effective causes of the malady. 


Anidrosis. 

(Gr. a, privative ; vdop, water.) 

(Anhidrosis. Ger. and Fr., Anidrose.) 

Statistical frequency in America, 0.009. 

This name is properly applied to those morbid conditions where no sweat is secreted 
from the surface of the body. Hypohidrosis is a term more exactly used to desig¬ 
nate a relative, general or partial decrease in the quantity of the sudoral fluid. 
The former term, however, is often used to indicate the latter. 

Complete anidrosis occurs naturally only when the sudoral apparatus 
has been involved in destructive or other changes in the skin (scars, 
atrophy, etc.). 

Diminution in the quantity of sweat excreted, or its complete sup¬ 
pression, whether general or local, is a symptom of several disorders, 
but as a separate cutaneous affection it has no existence. This condi¬ 
tion is sufficiently common in many cutaneous diseases, as, for example, 
ichthyosis, psoriasis, and some forms of eczema; but in these the 
symptomatic character of the anomaly is illustrated by the well-known 
fact that when the skin is relieved of these cutaneous troubles the 
function of sweat-secretion is restored. Similarly, in neuralgias and 
certain forms of paralysis, a circumscribed and temporary anidrosis 
may be the local expression of the nervous disturbance, precisely as in 
the case of the asymmetrical hyperidroses. Lastly, there are individ¬ 
uals exhibiting the idiosyncrasy of either sweating not at all or quite 
imperceptibly in elevated temperatures, phenomena which should be 
ascribed rather to peculiarities in the equilibrium of the heat-exchang¬ 
ing forces than to congenital deficiency of the sweat-glands. 

According to Geber, Strauss and Bloch regard the occurrence of 
hypohidrosis and anidrosis as differential diagnostic symptoms of 
diffuse myelitis and poliomyelitis as against cerebral paralysis. 

Treatment. The measures capable of stimulating the sweat-secretion 
are: Ingestion of water in quantity by the mouth, the external appli¬ 
cation of heat in a dry or moist atmosphere, and the use of jaborandi 
or pilocarpin by the mouth, or by hypodermatic injection. In the 
anidrosis accompanying cutaneous disease the indication is always 
primarily for the relief of the latter. 


DISORDERS OF THE GLANDS. 


105 


Bromidrosis. 

(Gr. fipa/ios, a stench; btiup, water.) 

(Bromhidrosis, Osmidrosis, Fetid or Stinking Sweat. 

Ger.y Stinkender Sch weiss.) 

Statistical frequency in America, 0.090. 

Symptoms. In bromidrosis the perspiration is effused in such a state 
that it can immediately be perceived to possess an unusual odor, or, as 
Hebra taught was the case with the majority of patients, to be rapidly 
changed to that condition. It is often associated with hyperidrosis, or 
may occur quite independently of the latter, and like the latter also 
be either general or partial. The odor may be either agreeable or dis¬ 
agreeable, having been in various cases compared to that of certain 
flowers and fruits, as well as to that of several stench-emitting animals. 
In this respect the sweat presents a striking analogy to the urine, with 
which it sustains a close and well-recognized physiological relation. 

General bromidrosis may be physiological, as in the case of indi¬ 
viduals of the African race, or in those with dark skins who are pro¬ 
fusely sweating during labor or in high temperatures. General 
pathological bromidrosis is rare. The odors emanating from the 
person in ulcerating syphilodermata, small-pox, and other general 
disorders may, in certain cases, be associated with the sweat-secretion, 
but in other cases they doubtless are connected with the decomposition 
of pathological products of the inflammatory process. 

The local varieties of bromidrosis affect the regions in which the 
sweat is oftenest secreted in excess and its immediate evaporation pre¬ 
vented, as in the axillae, the groins, the feet, the ano-genital, and inter- 
and infra-mammary regions. In a qualitative sense, every degree of 
odorousness is noted, from that which is merely slightly agreeable or 
offensive to the most intolerable stench. When complicated by a sebor¬ 
rhea in situations where the parts are not only warm, moist, and cov¬ 
ered by clothing, but also subjected to friction and remaining un¬ 
cleansed, the most intolerable and nauseous fetor is perceived. 

Sweat may be effused, in a normal condition, upon and within the 
articles of clothing worn, and subsequently generate a stench by chem¬ 
ical changes both in the clothing and the fluid by which that clothing 
is saturated. This fact should never be forgotten in the practical 
management of any case. 

Etiology and Pathology. Thin has recognized micrococci (bacterium 
fcetidum) in sweat obtained from the feet. Parkes concludes that the 
only cause of the disease is in covering the foot, as soldiers with uncov¬ 
ered feet do not suffer from this affection. It is occasionally due to 
emotional causes, to chronic alcoholism, or to the gouty state. 

Treatment. The treatment of bromidrosis is, in general, that of 
hyperidrosis already described. Thin 1 successfully employed stockings 
and cork soles thoroughly dried after being saturated for hours in a 
jar containing a solution of boric acid. The efficacy of this measure 

1 Practitioner, December, 1881, p. 2101. 


106 


DISEASES OF THE SKIN. 


he ascribes to the fact that the odor is the result of the development in 
the secretions of the bacterium fetidum. An ointmeut is also employed 
by him for similar purposes; it is produced by making a solution of 
the acid in glycerin and incorporating it with a fatty basis of white 
wax and almond oil, making thus a “ glycerated cream of boric acid.” 
Armingaud, of the French Academy, has reported excellent results 
following the subcutaneous injection of 3 grains (0.20) of the nitrate 
of pilocarpin, eight of which operations were successful in reducing 
the abnormal sweat-fetor. Clement Hawkins 1 finely triturates 15 
grains (1.) of the red oxid of lead, and to this adds gradually 1 ounce 
(32.) of Goulard’s extract. This preparation is used as a lotion fol¬ 
lowing a nightly foot-bath containing an ounce (32.) of alum. 

Fox ( loc . cit .) advises a 1 per cent, solution of chloral or of potas¬ 
sium permanganate as a topical application. 

Internally the sodium salicylate has been employed with success in 
5-grain (0.33) doses. 


Chromidrosis. 

(Gr. color; itdop, water.) 

(Ephidrosis Tincta. Ger. and Fr., Chromidrose.) 

Statistical frequency in America, 0.005. 

By this term is indicated the condition in which effused sweat exhibits an abnormal 
color—yellowish, reddish, greenish, or blackish. Cyanhidrosis is the term that 
has been employed to indicate blue sweating. 

In cases of chromidrosis there has usually been a copious secretion 
of fluid. Authors have variously attributed the color of the sweat to 
the presence of compounds of phosphorus, iron, cyanogen, indican, 
Prussian blue, haematiu, chromogen, and even to parasitic vegetations 
upon the skin-surface. Women, much more often than men, exhibit 
the free deposit of pigment upon the skin, and, in view of the admitted 
rarity of chromidrosis, the suspicion arises that in some of the cases 
reported there was free pigmentation of the surface by which the fluid 
exuded was immediately stained or colored. Duhring reports a single 
case of red sweating in a vigorous male patient. Usually, however, 
the phenomenon occurs in persons who betray some evidence of impair¬ 
ment of other organs than the skin, or who are debilitated in general 
health, thus furnishing an indication for their treatment. 

Babesiu, 2 of Pesth, reports some interesting cases of this disorder, 
which appears to have been produced by the presence of bacteria. In 
four patients, three of them women, there was considerable pruritus 
with pale-red to blood-red sweat; in one of the patients the skin and 
hairs were reddened. The axillae were the source of this colored 
perspiration. 

In all the cases microscopical examination revealed similar changes. 
The hairs of the axillae were thin, pale-red, brittle, and surrounded 
with a colloid-looking, rusty, or bright-red sheath, in places of consid¬ 
erable thickness and having a rough surface. This sheath consisted 


1 British Medical Journal, May 7, 1881. 


2 Lancet, 1862. 


DISORDERS OF THE GLANDS. 


107 


of red masses, presenting a radiating striation, more or less confluent, 
apparently proceeding from fibres of the cortex of the hair or from 
some broken part of its surface. The radiating striation was found to 
be. due to the aggregation of round or ovoid bacteria (scarcely a micro¬ 
millimetre in diameter), which were united in zoogloea masses by a 
reddish, intermediate substance. Nodular swellings ou the hair were 
produced by the infiltration of the organism between the separated 
fibrils. The roots of the hair were free from bacteria. The red tint 
of the sweat was found to depend upon numerous roundish masses of 
zoogloea. 

T. C. Fox 1 also reported two cases of cyanhidrosis in which a deep 
bluish-black pigment was exuded upon the skin of the circumorbital 
region. The amorphous granules were found insoluble in almost all hot 
or cold reagents, but they displayed a deep blue color when moistened 
with glycerin, and a purplish hue when dissolved iu hot sulphuric acid. 

The hypothesis, that certain cases described as chromidrosis are really 
instances of mechanical washing of pigment to the surface in the pro¬ 
fuse sweating of the debilitated, is strengthened by the phenomena of 
simultaneous hair-coloration. Thus, Prentiss 2 reports the case of a 
young woman, affected with acute cystitis and passing purulent urine, 
whose hair, under the influence of profuse sweating induced by the 
action of pilocarpin, changed speedily from a light blonde to a nearly 
jet-black hue. At the meeting in 1881 of the American Dermatolog¬ 
ical Association the author exhibited hairs of a middle-aged man that 
had changed in a night from a grayish-white to a greenish and yellow¬ 
ish-brown hue; and in commenting upon these, White, of Boston, 
stated that he had observed several similar cases of hair-coloration as 
the result of profuse sweats. In the year 1844 this observer reported 
to the Association the case of a workman in a sugar-refinery, whose 
sweat from the left side of the body was of a bright-yellow color for 
several months. Though sought for, no bacteria were discovered. 

In a case observed by Bergmann a mycelium was recognized which 
was subsequently cultivated on paste. Eberth has recoguized bacteria 
in both normal and yellow sweat. 

Le Boy de M6ricourt, first to name this disorder, 3 also 4 described a 
case of rosy sweating in an infant. 

Fer6ol believes that in these cases there is actually an absence of 
sweat and prefers to call the disorder “ chromocrinia.” 

In all cases, before accepting statements of patients as to the existence 
of symptoms of this character, it is needful to eliminate the possibilities 
of deceit and accident. Coloring-matters received upon the hauds may 
be, either iu wilful ness or ignorance, transferred to the surface of the 
body. 

Greenish Sweating, due to the presence of copper in the system, 
has been reported in a few instances. The author observed one case 
of this disorder where the effect was produced by the copper plate of 
an electrode in contact with an abraded surface of the skin. 


1 Med. Press and Circ., Jan. 1, 1881. 

3 Arch. gen. de Med., November, 1857. 


2 Phila. Med. Times, July, 2,1881. 
4 La France MSdic., 1884. 


108 


DISEASES OF THE SKIN. 


Phosphorescent Sweating is reported to have occurred after the 
eating of phosphorescent fish and the ingestion of phosphorus for 
medicinal purposes. 

The treatment of these several conditions is that of the general state 
of the patients exhibiting these symptoms. 


Uridrosis. 

(Gr ovpov , urine; vdup, water.) 

(Ger., Harnschweiss; Fr., Uridrose.) 

Uridrosis is that condition in which some of the constituents of the urine, chiefly 
urea, are excreted in excess with the sweat. 

While a small amount of urea is to be recognized in normal sweat, 
it may, under peculiar conditions, be increased, and, together with 
urinary salts, be deposited upon the skin-surface after evaporation of 
the exuded fluid. Such symptoms have usually occurred either as the 
result of grave constitutional affections (such as cholera), or of organic 
renal disease accompanied by anemia, or of the ingestion of jaborandi. 
In a few cases the symptoms have been presented in individuals who 
were apparently in good health. The salts of the urine appeared upon 
the skins of these patients in the form of minute lamellae, or of a fine 
powder of whitish color and crystalline aspect. In some cases reported 
the symptoms have been noted to precede by a few days a fatal issue. 

The constantly adjusted equilibrium between the sweat-secretion and 
the urinary excretion would explain, for cases of a mild type, tem¬ 
porary augmentation in the urea found in the sweat of unusually free 
diaphoresis. Geber supposes that decomposition-products, such as the 
carbonate of ammonium, possibly aided by the volatile fatty acids, 
may in part account for these conditions. 

Hjematidrosis, or bloody sweat, reported as observed by several 
authors (Foot, Ebers, Parrot), is a name applied to conditions in which 
blood has been seen to exude from an unbroken skin. The phenomena 
described under this title belong properly to the ensemble of symp¬ 
toms called u haemophilia,” and may in some cases be due to direct 
transudation of red and white blood-corpuscles and fibrin into the inter- 
epithelial spaces traversed by the sweat-pores. Geber points to the neu¬ 
ralgic, hyperesthetic, pruritic, or emotional symptoms that are usual 
precursors to the flow of pale or bright-red blood. The fact that the 
patients thus affected are mostly women, hysterical, dysmenorrheic, 
or near the puberal epoch, also throws light upon these cases; in many 
of them petechiae, or signs of hemorrhage into other tissues of the 
body, are observed. 

In the effort to eliminate certain substances, accidentally or pur¬ 
posely introduced into the system, the sweat may possibly become 
charged with iodin, turpentine, tar, arsenic, and other substances. 
Several of the eruptions described in the chapter on Dermatitis Medica- 


DISORDERS OF THE GLANDS. 


109 


mentosa are due to a similar eliminative effort, especially those accom¬ 
panied by excessive sweating and the production of vesiculation. 

In the same manner it may be inferred that the sweat is at times 
charged with excrementitious and other products of the body; as, for 
example, the principles of the bile. In patients affected with yellow 
fever the skin and sweat often exhibit the characteristic hue of that 
disease. The so-called “ galactidrosis,” from supposed metastasis of 
milk, does not occur; cases thus described have been instances of 
pathological sweat in the puerperal state. 


2. DISORDERS OF THE SEBACEOUS GLANDS. 

Seborrhea. 

(Lat. sebum , tallow; Gr. peo, to flow.) 

(Steatorrhea, Acne Sebacea, Dandruff, Seborrhagia, Seba¬ 
ceous Flux, Stearrhea. Ger ., Schmeerfluss; Fr., Sebor- 

RHEE.) 

Statistical frequency in America: Seborrhea, 1.47; S oleosa,0.296; S. sicca, 0.319. 

Seborrhea is a functional disorder of the sebaceous glands, exhibited in an abnor¬ 
mal condition of the secretion as it collects upon the surface of the skin. 

Most observers now believe that the clinical phenomena described 
under the title of seborrhea are not due solely to a catarrh of the seba¬ 
ceous glands, but result from several different pathological processes 
in which the coil-glands and epidermal layers are more or less involved. 
There is not yet, however, sufficient knowledge of the pathology of 
these conditions to warrant a new classification of them, and in these 
pages they are considered chiefly from a clinical standpoint. The more 
inflammatory processes in which the fat-producing glands seem to play 
an important part are now described under the head of dermatitis 
(eczema) seborrhoicum. 

Symptoms. Seborrhea occurs in two forms. According to the con¬ 
dition of the excreted product, they are known as seborrhea sicca 
and seborrhea oleosa. These two forms are recognized clinically as 
of separate occurrence, and also as existing occasionally at the same 
time in one person. Either form of the disease may be limited to 
certain sites of preference, or be generalized so as to extend over all 
portions of the body provided with sebaceous glands. The commonest 
seats of the disease are: the scalp, the face, the genital region, the 
dorsum of the body between the scapulae, and the anterior surface of 
the chest. It appears at all periods of life, and in both sexes. As 
the sebaceous glands are mainly appendages of the hair-follicles, the 
lesions of the disease differ somewhat, according as they exist in 
the regions covered with long or with lanugo hairs. For the same 
reason, a difference marks the career of the disease. At times it is 
a trivial and short-lived affection; at other times it is persistent and 
intractable, lasting for years and possibly for a lifetime. The indi- 


110 


DISEASES OF THE SKIN. 


viduals thus affected exhibit a difference also with respect to the gen¬ 
eral condition of their health. Some are anemic, chlorotic, or asthenic; 
some are of sanguine temperament, fleshy, red-faced, and thick-skinned; 
others again are absolutely healthy, so far as can be discovered, except 
for the local sebaceous disorder. The latter fact is of some significance. 
One may see exaggerated types of seborrhea in vigorous men who 
have worn merely for one month a skull-cap to which was fastened an 
apparatus for relief of fracture of the lower jaw. The skin affected 
with a seborrhea is usually ansemio and is either dry or humid. The 
subjective sensations are either slight and limited to a moderate degree 
of itching, of which the patient does not complain until he is ques¬ 
tioned upon the subject, or are altogether wanting. At other times 
the glands, or periglandular tissues, are affected with a mild form of 
inflammation, and then the involved surface may be reddened and 
become the seat of a considerable pruritus. 


Seborrhea Oleosa. 

This form of seborrhea, variously known as hyperidrosis oleosa 
(Brocq), seborrhea simplex (Unna), stearrhea simplex (Wilson), acn6 
s6bac6e fluente, etc., is in its pronounced features rarer than seborrhea 
sicca, but to a less degree it is a condition sufficiently common in many 
forms of the disease. The sebaceous secretion of the disease is poured out 
as an oily fluid upon the surface both of the hairy and so-called “ non- 
hairy ” parts of the skin In the former situation, both in adults and 
infants, the free oily substance is seen to cover as a coating both skin and 
hairs, and, especially in bald adults, to produce a glistening and shin¬ 
ing appearance of the scalp. It often concretes into masses, forming 
the crusts of seborrhea sicca. The same greasy layer can be seen in 
the non-hairy portions of the skin, especially about the nose, forehead, 
and cheeks, J'ree drops of oil can occasionally be wiped from such 
surfaces with a handkerchief. The ducts of the sebaceous follicles 
here are either patulous or plugged with comedones; the skin-surface 
may be reddened or be pallid, but it is usually cold to the touch. The 
oily substance serves to entrap particles of dust, soot, etc., floating in 
the air, thus a peculiarly dirty or even blackish hue of the face is often 
produced. This form of seborrhea, though most common on the face 
and scalp, may occur on the chest, the back, the pubes, and the genitals, 
and rarely on other parts of the body. In the negro, in whom the 
sebaceous glands are usually well developed and active, the oily forms 
of seborrhea are common, and the flux at times is almost physiolog¬ 
ical. Even in the absence of their frequent anointing with palm-oil, 
one can see in Africa the naked blacks whose skins shine from exuded 
grease. 

Subjective symptoms in seborrhea oleosa are usually slight, though 
a moderate amount of itching is commonly present. On the scalp the 
disease often produces an alopecia which does not, as a rule, respond 
readily to treatment. 


DISORDERS OF THE GLANDS. 


Ill 


Seborrhea Sicca. 

Seborrhea sicca, as the term is generally accepted, varies greatly in 
its manifestations, but in general they may be divided into the scaling 
and the crusting form of the disease. The scaling form, variously 
known as seborrhea furfuracea or pityriasiformis, pityriasis simplex, 
eczema seborrhocium squamosum, etc., is most common on the scalp, 
where it is popularly known as “ dandruff.” Seborrhea capitis in its 
commonest form is recognized in the adult by the formation on the 
scalp of fine, branny, slightly greasy, white or grayish scales, which 
may be so abundant and loose as to fall freely and cover the shoulders 
of the patient whenever the hair is brushed or otherwise disturbed. 
At other times these fatty scales are more or less adherent to the 
scalp-surface, or are piled up in laminae, one upon another. These 
scales may closely mat the hair together, perceptibly near the exit of 
the latter from their follicles, or be abundantly disseminated through 
the mass of the hair, some of the hairs penetrating a flattened greasy 
scale, as a twig might be passed through the centre of a leaf. In con¬ 
sequence of their deprivation of unguent, the hairs to which the affected 
glands are accessory become dry and lustreless, and fall from their 
follicles: If the process be not arrested, atrophy of the hair-follicle 
ensues, the resulting alopecia becoming permanent. 

Fortunately, the seborrhea is usually symmetrical, and, in like man¬ 
ner, the baldness which it occasions. The resulting disfigurement is 
of the character of symmetrical senile alopecia, which is chiefly annoy¬ 
ing because of the premature loss of hair. When this loss is asym¬ 
metrical, which is decidedly exceptional, the disfigurement is greater. 

The affection may be circumscribed, and in conspicuously exhibited 
patches, where thin, mealy, grayish, or whitish scales cover the patch; 
or thick yellowish masses may paste the hairs firmly to the surface of 
the scalp. The disease may extend over the entire surface of the scalp 
uniformly, or, as is frequently noticed, may fringe the brow at the line 
of the hairs, and then extend chiefly over the vertex, being conspicuous 
at the line where the hairs are parted from vertex to brow. 

Beneath the scales or crusts of dried sebum the scalp is usually 
lustreless and of a slate-gray color. As the disease does certainly 
occur at times intermediate between functional and inflammatory 
forms, the adjacent tissues may present a hyperemic or even an exu¬ 
dative feature, with true epithelial desquamation and considerable 
itching—alopecia pityrodes, pityriasis simplex. One group of cases, 
assignable to this class, deserves attention. In these cases there is a 
tolerably well-diffused seborrhea sicca of the scalp, and, irregularly 
distributed over the surface, are filbert-sized, generally circular, dark 
reddish patches, covered with a moist secretion or a friable, granular, 
reddish-yellow crust. These patches are scalp excoriations produced 
by the finger-nail. They are most common in “ nervous” patients, 
who cannot resist forcibly digging the scalp on the slightest provocation. 

The eyebrows, the region covered by the beard, and the pubic hairs 
may be affected, although less frequently, in the manner described 
above. In the latter region the itching is often more severe than 


112 


DISEASES OF THE SKIN. 


when the disorder is limited to the scalp. The disease not infrequently 
extends from the scalp to the adjacent portions of the face, neck, and 
ears. In these situations the skin is usually slightly reddened, while 
the scales are thin, adherent, and not very abundant. These features 
may appear on the portions of the face more distant from the scalp, 
and on other parts of the body in the form of dry, roughened patches 
which scale more or less but which are only slightly, if at all, reddened. 
On such surfaces the condition may shade insensibly into those described 
under dermatitis (eczema) seborrho'icum. 

The crusting forms of seborrhea may occur on any of the hairy or 
non-hairy parts of the body, but are most common on the scalp and 
face. Occurring in infancy, the disease is known as “ milk crust,” 
or as crusta lactea. This may merely be persistence of the dried ver- 
nix caseosa about the vertex in the newborn, or it may occur in scalps 
which have been perfectly cleansed after birth. The crust differs some¬ 
what in color with the tint of the child's complexion, and may vary 
from a light yellow to a dark brown; it may be thick, greasy, aud mat 
the hairs together; or be thin, dry, and friable. This crust is a fre¬ 
quent complication of the eczematous disorders of the scalp, and, as a 
consequence, every variety of hyperemia and inflammation may affect 
the tissue beneath the crust. In infants and children, however, the 
resulting alopecia is never permanent, as the rapidly growing follicles 
hasten to reproduce the hair. The disease is neither contagious nor 
followed by cicatrices, points upon which mothers are usually solicitous. 
The region of the brow, the surface covered by the beard of the male, 
and the pubic hairs may be involved in this type of the disease, 
though less frequently than in the furfuraceous form. 

On the face this form of seborrhea is characterized chiefly by the 
accumulation of thick, dirty yellowish, and even yellowish-black, accu¬ 
mulations of sebaceous matter, often adherent to the surface and dis¬ 
figuring the features by the artificial mask produced. This condition 
is exceedingly conspicuous about the nose, where the disease is at times 
symmetrically disposed. The crusts once removed, the skin beneath is 
generally found to be pallid or slightly reddened, w ith the orifices of the 
sebaceous ducts patulous; while the under surface of the separated crust 
is seen to project downward in corresponding delicate prolongations, 
which Kaposi compares to stalactites. The crusts rapidly re-form 
when the disease is not arrested. They are found in the furrows on 
either side of the nostrils, on the brows, the cheeks, and the pavilion 
of the pinna of the ear. They are most common at the puberal epoch 
in both sexes, when the sebaceous glands of the skin undoubtedly sym¬ 
pathize with the changes occurring in the beginning of the sexual life. 

Seborrhea may affect the eyelids, which are then reddened, slightly 
swollen, and more or less covered with minute crusts (less frequently 
with scales). The eyelashes often fall, and in cases of long standing 
their loss may be permanent owing to atrophy of the follicles. 

Seborrhea of the umbilicus assumes special features, since the fatty 
matters in this region are remarkable for their tendency to speedy 
decomposition, with the production of an exceedingly fetid odor, which 
may prove to be the source of a mild grade of inflammation. In the 


DISORDERS OF THE GLANDS. 


113 


latter event, there surrounds the umbilical depression a reddish halo, 
which may be the source of a thin, sero-purulent discharge. 

Seborrhea of the genitals is usually located in men in the sulcus 
behind the corona glandis, though in individuals with a tight or a 
redundant prepuce it may be more extended. In women the accu¬ 
mulation occurs about the clitoris and vestibulum, though the external 
labia may be covered with the secretion in various degrees of fluidity. 
The smegma preputii supplied by the glands of Tyson may thus be 
the source of trouble either by its retention, or its secretion in abnor¬ 
mal quantity or quality. In either event the tendency, as in umbilical 
seborrhea, is to decomposition, fetid odor, and subsequent irritation, 
which may provoke inflammation of severe grade. The retention of 
this smegma beneath a tight or a redundant prepuce in men may pro¬ 
voke a long list of reflex symptoms, such as inco-ordinated move¬ 
ments in the lower extremities, nocturnal enuresis and pollutions, 
hernia, and irritability of the testis. In some cases the secretion forms 
a ring (as hard as the rind of cheese) encircling the glans. It should 
be remembered that the young of both sexes as well as adults are liable 
to be thus affected, and that in young female children these symptoms 
may have a medico-legal interest in connection with suspicion of 
criminal attempts. 

Seborrhea generalis affecting the entire surface of the body is an 
exceedingly rare disorder. In the infant (seborrhea squamosa neona- 
torum , ichthyosis sebacea ) the skin is universally spread with a greasy 
layer, which is rapidly renewed after removal, and beneath which the 
skin seems to be varnished iu reddish-brown shades. The consequent 
stiffening of the integument produces painful fissures, inability to take 
the nipple, and consequent marasmus. 

In adults the disease may occur in marasmic subjects and in old 
people in the form of a persistent fine scaling on the trunk and extensor 
surfaces of the limbs, and is known as u pityriasis tabescentium/ A 
yet rarer form is described by Kaposi under the name of u cutis tes- 
tacea”, in which large portions of the skin, especially the extensor 
surfaces of the limbs, are covered with greenish-brown or black crusts 
which are more or less broken up into plates. 

Etiology. Seborrhea may be due to local or to general causes. 
This point should clearly be understood, as Hebra^with his superb 
powers of observation, noticed that the majority of his cases of sebor¬ 
rhea occurred in young male and female subjects affected with chlorosis 
or conditions analogous to that state. It is a clinical fact of iead^ 
verification; but it is clear that many cases are essentially of local 
origin, and, as before indicated, a seborrhea can artificially be pioduced 
in a healthy individual in the course of a few weeks by very simple 
local measures without interference with the general economy. Women 
with long hair are usually disposed to take special care of the scalp 
upon which it grows. Men with short hair are more apt to attend 
chiefly to its disposition upon the head, and to neglect the care of 
the scalp. Such neglect is sufficient cause in some cases to produce 
seborrhea sicca of this region. But for other types of the disease, and 
especially when it occurs on the non-hairy portions of the skm, in by tar 


114 


DISEASES OF THE SKIN. 


the greater number of all cases, chlorosis, struma, malnutrition, obsti¬ 
nate constipation, disorders of digestion and menstruation, and seden¬ 
tary habits of life, are unquestionably responsible. The exanthematous 
and other fevers are often followed by asthenic states in which the 
same condition prevails. Hebra pointed out the fact that the sebum 
of individuals who have fatty livers from chronic alcoholism is pecu¬ 
liarly fluid and oily; and it will be observed that few of all the disor¬ 
ders of the sebaceous glands characterized by inspissation of the 
secretion occur in such persons. 

Seborrhea oleosa is found more frequently in persons of dark com¬ 
plexion, while seborrhea sicca is more common in blondes. A family 
tendency to furfuraceous seborrhea of the scalp, and a resulting alope¬ 
cia, may often be noted. 

Among the indirect causes of this affection, as also of several other 
diseases of the sebaceous glands, may be named: the excessive use of 
tobacco; the wearing of stiff, heavy, and ill-ventilated hats; chronic 
alcoholism, gout, and syphilis. 

Many clinical facts point strongly to the parasitic origin of the con¬ 
ditions described as seborrhea sicca, but definite and satisfactory knowl¬ 
edge on this point is wanted. 

Pathology. Seborrhea oleosa in its simplest form is presumably a 
hypersecretion of the fat-producing glands. Unna’s position, that the 
coil-glands are active agents in this process, is now accepted by many 
authors and is probably correct, although other investigators, adopting 
the methods of Unna, have failed to obtain his results. 

Seborrhea sicca has been supposed to be due to an abnormal func¬ 
tional activity and an imperfect fatty metamorphosis of the cells of 
the sebaceous glands. The fatty crusts, however, contain not only 
abnormal products of the fat-producing glands, but also exfoliated cells 
of the epidermis and hair-follicles. Many observers now believe that 
most of the conditions described under seborrhea sicca are primarily 
inflammatory and probably parasitic in origin, and that in some of the 
simple pityriasic forms the sebaceous glands are not involved. It 
should be remembered, however, that furfuraceous seborrhea may 
exist for years without clinical evidences of inflammation. This ques¬ 
tion is further considered in connection with dermatitis seborrho’icum. 

According to Unna’s investigations, alopecia precedes atrophy of the 
papillae, and in the early stages is due to a choking of the upper part 
of the hair-follicles with horny cells. The bed-hairs are thus loosened 
from the follicle and shed, while the lower part of the follicles, the 
papillae, and the papillary hairs are intact. As the process continues 
the follicles are gradually dilated and filled with horny cells to a greater 
depth until the entire follicle, including the papilla, is atrophied and 
permanent alopecia results. 

Diagnosis. Seborrhea is to be distinguished from : 

Eczema. The objective points of difference between eczema and 
seborrhoea depend upon the inflammatory character of eczema, upon the 
reddened, infiltrated, or discharging skin, and upon the considerable 
degree of itching which it occasions. In squamous eczema the scales 


DISORDERS OF THE GLANDS. 


115 


are rarely so abundant as to be shed freely from the surface, and are 
not greasy. It should be remembered, however, that the two diseases 
may and do coexist. Inflammation of those parts of the skin well 
supplied with sebaceous glands usually assumes one of the types de¬ 
scribed as dermatitis (eczema) seborrhoicum. Eczema of the scalp in 
infants is especially apt to be accompanied by a seborrhea, a fact which 
clearly shows that the technical distinctions between many diseases, 
useful though they be for analytical study, are not always capable of 
clinical demonstration. 

Ichthyosis. This is a congenital disease, usually involving the 
entire surface of the body, while seborrhea is generally acquired and 
is rarely universal. The distinction between ichthyosis and the rare 
generalized forms of seborrhea described above might involve a diffi¬ 
culty; but in the latter the greasy character of the crusts, their color, 
and the marasmic condition of the subject of the disease would suffi¬ 
ciently distinguish the two disorders. 

Impetigo and Impetigo Contagiosa. In these two maladies the 
only possibility of error in diagnosis would originate in the discovery 
of either of the two diseases in the stage of crusting, especially upon 
the scalp. But both are acute disorders, with comparatively small, 
circumscribed, and isolated lesions, with crusts differing in character 
from the sebaceous matters formed in seborrhea, and beneath such 
crusts the integument is reddened and evidently the seat of an exuda¬ 
tion. 

Lupus Erythematosus. Lupus erythematosus, though occurring 
on the face, is rare on the scalp; it is accompanied by characteristic 
changes in the structure of the skin, and is often followed by a scar. 
Its lesions are darker red than the congestive patches beneath certain 
seborrheas of the non-hairy parts. The scales of lupus are tena¬ 
cious and dry, and require scraping for their removal; those of seb¬ 
orrhea are greasy and more readily detached. The contour of the 
seborrheic patch is ill-defined compared with that of lupus, which 
is very distinct, exception being made of the mask-like crusts seen in 
certain of the facial seborrheas, where the greasy character of the 
layer is very evident. Hebra, in 1845, described a “ seborrhea con¬ 
gest va,” which it would indeed be difficult to distinguish from lupus 
erythematosus, as the former is really an early stage of the latter. 
Typical cases of the two diseases are widely different and readily dis¬ 
tinguished; the atypical forms might lead to confusion. 

Psoriasis. Psoriasis of the scalp may resemble seborrhea sicca, 
but the latter is rarely developed in such a universal exanthem as is 
frequent in the former. There will come under observation few 
doubtful cases in which a psoriatic patch on the elbow, the knee, the 
leg, or over the sacrum, will not point to the nature of the disease. 
The scales of psoriasis are lustrous, larger, and not greasy, unless fatty 
applications have been made to soften them; and, moreover, they cover 


116 


DISEASES OF THE SKIN. 


a reddened and exuding patch of integument. Psoriasis of the scalp 
and face prefers the areas of the forehead adjacent to the hairs of the 
scalp, and rarely departs boldly to the nose and the furrows beside the 
nostrils—favorite sites of seborrhea. In seborrhea of the scalp the 
hairs are loosened and fall, a condition not found in psoriasis. 

Syphilis. Some forms of the pustular syphilodermata located upon 
the scalp and face, if observed only in the stage of crusting, might be 
confounded with seborrhea. Here the history of the case, the discov¬ 
ery of other signs of syphilis (adenopathy, mucous patches, etc.), and 
the character of the secretion and the surface beneath the crust, 
together with the smaller size, more definite outline and characteristic 
grouping of the lesions, should point to the identity of the disease. 
In syphilitic crusts about the angles of the nostrils there is often a 
peculiar reddish-brown tint of the skin at the edge of the patch, the 
so-called “ copper” color, which is significant. Crusts of the hairy 
scalp in syphilis are very often accompanied by post-cervical adenop¬ 
athy, and especially by indurated enlargement of the occipital glands. 

Tinea Circinata and Tinea Tonsurans. In ringworm of the 
hairy parts, as also of the body, the microscopical discovery of the 
parasite will always point to the nature of the disease. Upon the 
scalp the affected patches are seldom so diffuse as in seborrhea, are 
usually circular, are often accompanied by fragility of the hairs, and, 
in the latter case, the discovery of stumps of hairs is significant. 
There is also a history of contagion and absence of the greasy condi¬ 
tions of the scales characteristic of seborrhea. 

Treatment. The general and internal treatment of seborrhea should 
be varied to meet the requirements of the individual case. The prep¬ 
arations most often indicated are: Iron in anemic young women, 
cathartics in sluggishness of the bowels, and cod-liver oil when there 
is impairment of nutrition. Duhring recommends the sulphid of 
calcium in doses of from y 1 ^ (0.0066) to \ (0.0133) of a grain. Arse¬ 
nic, employed in the manner suggested by Sir Erasmus Wilson, is 
praised by Hebra: 

R. —Vin. ferri, f^jss; 50; 

Syrup, simpl., \ aafzU- s' 

Liq. potass, arsenit., / I 3 1 J> 8 

Aq. destill, f^ij; 60* M. 

S. —A teaspoonful to be taken three times daily with the meal. 

In many cases, the acid iron mixture of Startin, or some modifica¬ 
tion of it, admirably meets the indications present: 

R. —Magnes sulph., ^ij; 641 

Ferri sulphat., ^ss-^j; 0.66-133 

Acid, sulph dilut., f 3 ij-fiv; 8-16| 

Infus. quassise, adf^iv; 1281 M. 

S. —A teaspoonful in water, to be taken through a tube after eating. 

The preparations of matzool, malt, and maltine, now largely em¬ 
ployed in the treatment of wasting diseases, will be found available 



DISORDERS OF THE GLANDS. 


117 


in cases where cod-liver oil cannot be well taken. Lastly, the bitter 
tonics may be needed. Throughout the treatment the physician should 
insure a careful observance of the laws of hygiene. Sunlight, nutri¬ 
tious food, and open-air exercise are not to be disregarded. Many 
young women of indolent habits are greatly benefited by sending them 
daily to the riding-schools for an hour’s equitation. 

The author is in the habit of ordering, in cases where it can be toler¬ 
ated, daily cool, salt-and-water sponging of the entire body-surface, 
followed by brisk friction. The salt is added to the water in the 
strength of one-quarter of a pound to the gallon. There is no advan¬ 
tage to be gained by using the preparations of ee sea-salt” sold in the 
shops. The bath is omitted during the menstrual period in women, 
and in the case of delicate patients. It is, without question, the most 
valuable of all hygienic measures in the management of the disease. 

The first indication to be met by local treatment in seborrhea is the 
removal of the crusts and the fatty matters accumulated upon the 
surface. Upon the scalp it is always well to warn patients, especially 
if the disorder be aggravated and occurs in young women with appar¬ 
ently luxuriant tresses, that a considerable loss of hair will result. 
Many of the filaments are so impoverished by the chronic course of 
the disease and so loosened in their follicles, that a complete cleansing 
of the scalp-surface will bring the hairs away in quantities sufficient 
to threaten speedy baldness; and it is not rarely the case that patients 
attribute this to the treatment rather than to the disease. The fatty 
accumulations are first to be soaked in some oily fluid to facilitate 
their removal; for this purpose olive oil, cod-liver oil, vaselin, cold 
cream, almond oil, glycerin, or lard is usually employed. The sub¬ 
stance selected should be used in excess, and in quantity sufficient to 
permeate all crusts. It may be poured over or be rubbed into the 
scalp several times in the twenty-four hours, and at night a flannel or 
other cap be worn to insure still further success. In the case of chil¬ 
dren and infants considerable gentleness is required in thus treating 
the scalp, especially in the subsequent washings, lest the surface be 
irritated. In young women it is rarely necessary to cut the hair. As 
soon as the soaking with oil is insured the crusts are to be removed 
by washing with soap and water, though when the accumulations are- 
bulky masses may be gently removed with the fingers or a comb. 
When the scalp is quite tender ordinary toilet, or Sarg’s glycerin soap, 
may be applied with warm water; but it is usual, in the case of adults, 
to employ the spiritus saponis kalinus of Hebra—two parts of green 
soap digested in one of alcohol, filtered and flavored with lavender or 
bergamot. The surface should be thoroughly sponged with spirit, and 
then warm water added until the foam of the lather is abundantly 
produced over the scalp, when an excess of water is finally used to 
cleanse the part of crusts, oil, and soap. The scalp and hairs are then 
thoroughly dried and anointed with some bland, fatty substance, if 
the exposed surface be tender and irritable; if not, with some stimu¬ 
lating pomade or lotion. 

In cases where milder effects are required the scalp may be washed 
in water containing such alkaline substances as borax, ammonia, or 


118 


DISEASES OF THE SKIN. 


the carbonate of potassium. The popular prejudice against these 
articles is based upon the abuse of strong alkaline lotions in the hands 
of inexperienced persons. Such lotions may readily be tested by the 
tongue for the degree of softness required for the scalp. They should, 
in the management of all cases, be followed by an oily or greasy appli¬ 
cation medicated to meet the requirements of the case. 

The last-named precaution is an important one. However exten¬ 
sive the seborrheic crusts, it is possible to remove them completely 
in every case by the measures described above, and with the first 
experiment patients are often delighted. Their disappointment is 
correspondingly great when they discover that the seborrhea is not 
yet at an end, aud that, in the course of a few days, the fatty plates 
are as freely as ever deposited on the scalp, disseminated through the 
hairs, and showered upon the shoulders. Some will even declare that 
the soapy applications aggravate the disorder by increasing the sebor¬ 
rhea. It should, therefore, never be forgotten that, having disposed 
of the extraneous matters accumulated upon the surface, there is still 
to be remedied a functional disorder of the sebaceous glands of the 
part. 

In every case, then, after the use of the soap and water, which may 
be repeated as often as need be, daily, at intervals of several days, 
or once in the week, the scalp is to be thoroughly anointed. For this 
purpose olive oil, cod-liver oil properly scented, almond oil, vaselin, 
or glycerin and water may be used. Van Harlingen recommends, as 
a substitute for other oils, the oleum sesami (oil of benne), since it does 
not dry and clog, as do the former. An ounce (32.) of this oil rubbed 
up with 5 grains (0.33) of powdered benzoin, and digested for three 
hours over a water-bath, with the addition of 3 drops of absolute alco¬ 
hol, and filtered, furnishes an excellent basis for oily mixtures to be 
used on the scalp. 

Morrison 1 has devised an ingenious instrument for the application 
of oily fluids to the scalp. The fluids are contained in a small reservoir, 
to which is connected a comb with perforated teeth; through the latter 
the substance selected for medication of the scalp readily passes down 
to the surface between the hairs. A medicine-dropper, though less 
convenient, will answer the same purpose. 

In the place of oils after these ablutions the ointments are often used 
with more advantage. For this purpose vaselin, lanolin, lard, and 
the oleate- or oxid-of-zinc ointment form the best bases. To obtain 
the desired consistency, either one of these may be used alone or in 
combination with the others or with an oil. 

Crocker advocates preceding the application of oily preparations to 
the scalp by a lotion containing acetic acid, the object being to aid the 
penetration of the remedy. 

Of the many remedies employed and recommended, resorcin, sul¬ 
phur, and the red ox id, bichlorid, or ammonio-chlorid of mercury are 
the most serviceable, and they suffice for almost all cases. Elliott 
states that resorcin aloue gives him satisfactory results in the great 


1 Maryland Medical Journal, January, 1885. 


DISORDERS OF THE GLANDS. 


119 


majority of cases. This remedy may be used in a spirit-lotion (from 
25 to 75 per cent, of alcohol) in strength varying from 2 to 10 per 
cent., or in the form of an ointment (10 to 80 grains to the ounce). 
Lotions are well adapted to cases in which there is little inflammation 
and in which decided stimulation is required. As they are cleanly 
and easy of application, they are more pleasing to most patients, and 
especially to women with long hair. Their efficacy is often improved 
by the addition of a small amount of oil. The bichlorid of mercury 
is admirably adapted for use in lotions. A good formula is as follows: 


R-—Hydrarg. bichlorid., 

01 . amygdal. dulc., 

Tinct. cantharid., 

Spts vin rect., 

Aq. destill., 

S-—To be rubbed into the scalp. 


gr- 5 

gy; 

Jy; 

q. s. ad f 3 vj ; 


15 


8 


64 

192 


M. 


Sulphur enjoys a high reputation in the treatment of all sebaceous 
gland disorders; in the form of an ointment, 1 to 2 drachms (4.-8.) 
to the ounce (32.) of cold cream, it is often of service. It may also 
be used as a powder, either alone or in combination with talc, salicylic 
acid, ‘boric acid, starch, or camphor; and as a lotion with alcohol, 
glycerin, and rose- or cologne-water. The alterative effect of the 
mercurials is also as evident in seborrhea as in many other cutaneous 
disorders. At the head of the list, for this special purpose, stands the 
red oxid of mercury in strength of from 2 to 4 grains (0.133-0.266) 
to the ounce (32.) of ointment; but white precipitate, ammoniated 
mercury, and calomel, in the proportion of from 5 to 10 grains 
(0.333-0.666) to the ounce (32 ) may be often substituted for the former 
with advantage. Carbolic, salicylic, and boric acids, from 1 to 5 per 
cent, in alcoholic solutions, with or without the addition of oil or of 
glycerin, are often of service. The tars are useful in many obstinate 
cases. Tar-soap may be employed in the washing; or oleum rusci 
added in the strength of one to ten parts to the other salves recom¬ 
mended above. Ichthyol in ointments of the strength of from 5 to 10 
per cent., and resorcin in spirit-lotions of 10 grains (0.66) to the ounce 
(32.) have also proved efficacious. Beside these substances, tincture 
of cantharides, capsicum, and nux vomica are frequently incorporated 
with advantage into lotions and pomades for use upon the scalp. Most 
of the pomades can be rendered sufficiently fluent for use in this situ¬ 
ation by adding 1 drachm (4.) or 2 (8.) of glycerin to the ounce (32.) 
of lard or of cold cream. Veiel recommends the following formula: 


R. —Extr cinchon. frig, par., 

Bals. Peruv. 

Cantharid tinct , 

Succ. citri, 

Ungt. pomat., 

S. —To be rubbed into the scalp once 


9j; 

gtts. xv; 
gtts. xxiv- 3 ss; 

Iflxv; 

3jss; 

or twice daily. 


1 5 
1 

1.5-2 

1 

50 


M. 


Repeated applications and patient care of the scalp are necessary to 
secure complete relief in the case of a disease as essentially chronic as 
seborrhea. At times the local treatment may be changed with advan¬ 
tage. Not infrequently too vigorous treatment is followed by a more 





120 


DISEASES OF THE SKIN. 


or less acute dermatitis. In this case stimulating preparations should 
be replaced by soothing ointments or lotions until the induced inflam¬ 
mation has subsided. 

The treatment outlined above for the hairy portions may be used 
with success also for the relief of seborrhea of the non-hairy portions 
of the body, especially the face. Here, it will be observed, the crusts 
have a singular tendency to re-form, and the most persistent care is 
necessary to secure permanent relief. Occasionally, after, cleansing 
the surface by soap and spirit-lotions according to the indications of 
each case, it is of advantage to apply the ointment selected for subse¬ 
quent application, not only by gently smearing it on the part with the 
tips of the fingers (always the most effective method), but also by 
spreading it on a compress, which, for the night at least, may be fixed 
in contact with the part. 

Unna’s lead-plaster mulls, used for this purpose in Germany, may 
fairly well be imitated by drawing strips of cheese-cloth through 
heated diachylon ointment and then smootlily smearing them with the 
same material. 

When this tendency to re-formation of the crust is abated, one or 
more of the dusting-powders may at times be employed with advantage 
for the purpose of protecting the skin or of exercising upon it an 
astringent effect. 

Seborrhea oleosa is best treated with lotions or with powders. 
Should the skin become irritated under these applications, ointments 
may be substituted for a time. Astringent lotions or powders contain¬ 
ing tannin, gallic acid, sulphate of zinc, sulphate of iron, oxid of 
zinc, subnitrate of bismuth, etc., are often serviceable. 

The local treatment of seborrhea of the genitals is somewhat differ¬ 
ent. Ointments rarely answer well in disorders of the mucous sur¬ 
faces, and green soap is too irritating for similar employment. Here 
washing with a good toilet-soap and warm water is sufficient for the 
purposes of cleanliness, and diluted lotions containing alcohol, in the 
form of whiskey, brandy, or aromatic wine, suffice to procure relief. 
These lotions can be made astringent with tannin, alum, or the zinc 
sulphate, and, when there is pain or tenderness, opium may be added. 
In this form of the disease, as also in seborrhea of the umbilicus, 
carbolic acid or chlorinated soda may be necessary to correct fetor. 
After the employment of these lotions boric acid, with talc (one part 
to four); or zinc oxid and starch (one part to eight), may be dusted over 
the part. In the generalized varieties of the disease the surface is to 
be thoroughly anointed with oil. The body, especially that of infants, 
is to be swathed in flannel or other good non-conductor of heat, and 
a roborant treatment directed to the general adynamia. 

In the grave forms of seborrhea of infants (described as keratosis 
sebacea, ichthyosis sebacea, etc.) the body must be kept anointed with 
oils or fats. Artificial feeding is demanded by the condition of the 
mouth. 

Prognosis . In forming a prognosis in cases of seborrhea it must 
be remembered that the disease is frequently an obstinate one, and that 
the resulting loss of hair, if symmetrical, may be remediless. Much 


DISORDERS OF THE GLANDS. 


121 


may be done in the way of saving the hair which is left. Facial sebor¬ 
rhea is much more amenable to treatment; seborrhea of the genitals 
and the umbilicus is an entirely manageable disease. When the affec¬ 
tion is generalized the prognosis is in the highest degree unfavorable. 


Asteatosis. 

(Gr. a, privative; areap , fat.) 

(Ger . and Fr. y Asteatose.) 

Statistical frequency in America, 0.006. 

Asteatosis is that condition of the skin in which there is absolute or relative defi¬ 
ciency of the sebaceous secretion. 

Symptoms. Insufficient lubrication of the skin by its natural un¬ 
guent may be either general or partial, and occur either as an idio¬ 
pathic or a symptomatic disorder. It is produced artificially by any 
agents which continually withdraw the fatty substance from the "skin- 
surface, as in those trades necessitating the constant immersion of any 
part of the body in strong alkaline solutions, or in waters highly im¬ 
pregnated with the salts of lime and potash. As an idiopathic affec¬ 
tion it is of very rare occurrence, but it is not an infrequent accom¬ 
paniment of other local or constitutional diseases, such as psoriasis, 
lepra, angioma pigmentosum et atrophicum, ichthyosis, and lichen 
ruber. In these cases the skin becomes dry, often thickened and indu¬ 
rated, and, as a consequence, friable, and prone to desquamation, 
fissures, and chaps. To the touch, the absence of sebaceous secretion 
is noticeable in the objective sensation produced. It is a well-marked 
feature of the marasmus of old age. Some authors have described 
under this title the dry thickening and induration of the palm of the 
hand, accompanied by curving of the fingers toward the plane of their 
flexor tendons, a condition which is occasionally to be observed among 
laundresses; but considering the absence of sebaceous glands from the 
palm, where in the author’s experience the affection is most prouounced, 
it should properly be excluded from the list of sebaceous disorders. 

Treatment. No internal medicaments are known to have the power 
especially of stimulating the sebaceous secretion. None, indeed, could 
be capable of having such action when, as is often the case in the dis¬ 
orders characterized by asteatosis, there has resulted an atrophy of the 
sebaceous glands. The most that can be accomplished is the external 
application of an artificial unguent, for which purpose cod-liver oil, 
almond oil, lanolin, palm oil, vaselin, lard, or butter may be employed. 
Vaselin is in mauy cases to be preferred, as the other articles named 
are liable to become rancid after oxidation, and thus act as irritants to 
the skin. Elliott prefers liquid albolin or benzoinal. With such partial 
or general lubrications, however, a warm bath of soap and water should 
be ordered every second or third day; immediately after the bath the 
inunction may be repeated. 

Prognosis. In all cases where the asteatosis is induced by agents 
operating externally upon the surface a reasonable hope of recovery 


122 


DISEASES OF THE SKIN. 


may be entertained after the withdrawal of the cause. Persistence 
of the latter is liable to be succeeded by the occurrence of eczema or 
dermatitis medicamentosa. A complete cure can scarcely be expected 
when this condition is really a symptom of one of the disorders already 
named. 


Comedo. 

(Lat. comedo, spendthrift.) 

(Black-head. Ger., Mitesser ; Fr., Acn£ Ponctuee.) 

Statistical frequency in America, 0.989. 

Comedo is a disease in which an inspissated secretion, lodged in the t excretory ducts 
of the sebaceous glands, becomes visible upon the surface in yellowish-white or 
brownish-black points. 

Symptoms . Comedones, which occur exclusively in the ducts of the 
sebaceous glands, consist each of a whitish fatty plug formed by the 
inspissation of the secretion of these glands, one extremity of the plug 
being visible at the surface when it is in situ. Occasionally the come¬ 
dones project to an appreciable distance above the general level of the 
integument, but often the extremity of each plug is slightly depressed 
below that level. There may be but two or three comedones upon 
the face, which is their commonest seat; or the nose, forehead, cheeks, 
and chin, the front and back of the neck, the back of the trunk, and 
the penis may thickly be studded with them. The visible extremity 
of the comedo varies in size from that of a needle-point to that of a pin¬ 
head. Comedones are readily expressed from the follicles in which 
they are lodged, and when thus examined they are seen to be whitish 
moulds of inspissated sebum, one or two lines in length, the exposed 
extremity of each comedone having become blackened by the dust 
and dirt entrapped at that point. In consequence of this suggestive 
appearance of the mass the disease has vulgarly been called “black¬ 
heads” and “skin-worms.” The deformity produced in the face 
when these lesions exist there in large numbers is strikingly con¬ 
spicuous, and it is for the relief of this appearance chiefly that the prac¬ 
titioner is consulted. The subjective symptoms awakened are of 
trifling moment. The disorder is essentially chronic in its course. 
Isolated comedones may be observed for years in one situation without 
apparent change or modification of any sort, and without producing the 
slightest local or constitutional derangement. Others appear, only to 
disappear under the influence of the usual hygienic regimen of the 
skin of the face. Others, again, serve to irritate the skin in which 
they are implanted, precisely as though they were foreign bodies; and 
the sebaceous glands and periglardular tissues, with and without the 
operation of such cause, exhibit grades of hyperemia and inflammation. 
Comedones may occur as the sole lesions of the skin, even to the extent 
of very great multiplicity, or they may coexist with other diseases of 
the glands, chiefly acne. They may occur at any period of life, but, 
like seborrhea, are most frequently observed at the puberal epoch in 


DISORDERS OF THE GLANDS. 


123 


both sexes According to Kaposi, the disease tends to disappear in 
women earlier than in men, in whose case it may be prolonged to the 
twentieth or the thirtieth year. 

Crocker has called attention to the occurrence of comedones in cliil- 
dien, with a special tendency to grouping in places subjected to heat 
and moisture, and also to their occurrence upon the hairy scalp. 


Fig. 35. 



Section of a comedo : a, excretory duct of a sebaceous gland filled with a comedo; it contains 
also two small hairs with brush-like inferior extremities ; into it opens a small hair-follicle (c) 
whose contained hair ( d ), after touching the opposite wall of the duct, curves downward at/. 
(After Kaposi.) 

Occasionally a so-called “double” comedo is formed, there being 
expressed from the skin a plug of inspissated sebum, each extremity 
of which is discolored. Whether this double comedo is due to a 
duplicity of efferent ducts in a single gland, or to an artificial or path¬ 
ological connection between two adjacent glands, is not clear . 2 

Etiology. Much has been written with reference to the improper 
care of the skin as a cause of comedo, the neglect of soap in washing 
the face, and the influence of the trades, as in the case of those who 
work in metals, dust, and tar; but observation shows that these are 
exceptional causes. On the one hand, very obstinate and generalized 
lesions occur in the skin of intelligent young men and women of the 


1 Lancet, April 19,1884. 


2 Ohmann-Dumesnil: Journ. of Cut. and Ven. Dis., Feb. 1886. 





124 


DISEASES OF THE SKIN. 


upper social classes, who regularly wash their faces with toilet-soap, 
who are rarely exposed to dust, and whose habits and recreations are 
of the most healthful character. On the other hand, observing the 
grimy faces of coalheavers, machinists, masons, and ink-manufacturers, 
one is impressed with the singular rarity of the disease in such laborers. 
Other causes of the constipation of the gland are unquestionably to 
be sought for in most cases. It is true that chlorotic young women, 
affected also with dyspepsia and torpor of the bowels, may exhibit the 
disease; and it is equally certain that many cases occur in peculiarly 
thick-skinned brunettes, or in men with a characteristic reddish-brown 
and greasy-looking complexion. Nevertheless, many such individ¬ 
uals never suffer from comedones, while often a perfectly healthy, fair¬ 
skinned girl will be greatly mortified by the disfigurement of her face. 

In yet other patients there is unmistakable connection between this 
disorder and chlorosis, scrofulosis, dyspepsia, habitual constipation of 
the bowels, menstrual derangements, and cachexia. This connection 
is demonstrated by the remarkable improvement manifested in the 
untreated skin when improvement of the general health is assured. 

Pathology. The mass termed the u comedo ” is a collection of con¬ 
centrically packed epithelial plates mingled with masses of cholesterin, 
of fragments of epithelia that have undergone fatty transformation, 
of minute lanugo-hairs, and, occasionally, upon the exterior, of the 
acarus folliculorum. This little mite, first detected by Henle in the 
ceruminous glands, was by Simon and others once thought to be the 
cause of the comedo, a view now abandoned by all dermatologists. 
This parasite, in persons upon whose skin it exists, can be detected in 
masses of commingled sebum and epithelial plates scraped from the 
free surface of the integument, as also upon the skin-surfaces of those 
who do not exhibit any disorder of the sebaceous glands. 

The comedo-plug is located either in the excretory duct of the seba¬ 
ceous gland or in the pouch-shaped canal common to the sebaceous 
gland and the hair-follicle. It will be remembered that in the class of 
sebaceous glands chiefly involved in the comedo the hair-follicle is 
rather an appendage to the gland, the relation between the two, evi¬ 
dent upon the scalp, for example, being here reversed. According 
to Biesiadecki, the hair-follicle in such cases often forms an obtuse 
or even a right angle to the duct of the gland, and the point of the 
hair being thus projected against the wall of the duct is occasionally 
curved downward upon itself, thus exciting an irritation at the point 
of impact and a subsequent multiplication of the protoplasmic elements 
lining the canal. Thus he explains the epithelial character of the 
outer envelope of the plug; the special occurrence of the disease at the 
puberal epoch, when, as is well known, there is an especially active 
growth of the hairs; and, lastly, the frequent discovery of lanugo- 
filaments in the expressed contents of the common excretory duct. 

Diagnosis. The recognition of the disorder is attended with no 
difficulty, patients themselves being usually sufficiently observant to 
identify the affection, though frequently misled as to the character of 
the “ skin-worm.” It is, as might be expected, a frequent coincident 
of acne; its lesions, when commingled with those of the disease last 


DISORDERS OF THE GLANDS. 


125 


named, being either in preponderance or so infrequent as scarcely to 
attract the attention of the patient. A condition somewhat resembling 
comedo may be produced upon the face when tar or ointments of 
mercury and sulphur are applied to it at the same time, the resulting 
black sulphuret appearing conspicuously at various points upon the 
skin, often at the orifices of the sebaceous glands. 

Treatment. The internal treatment of the patient affected with 
comedo is largely that described in connection with the subject of 
seborrhea. Cod-liver oil, iron, the bitter tonics, and preparations 
indicated by any special condition of the patient’s health are not to be 
omitted. Open-air exercise, daily cool salt-and-water bathing, as in 
the management of seborrhea, and the avoidance of all medicinal and 
dietary articles which might tend to aggravate the disorder, are also 
imperative. 

Even aggravated cases of comedo are completely relieved by natural 
processes in the course of time. These processes are, however, slow, 
and may require years for their completion. The rarity of comedones 
in middle life and advanced years sufficiently attests this fact. Presum¬ 
ably this natural cure is due to more vigorous growth of lanugo-hairs 
with the increment of age, which thus slowly push forward to the surface 
the excrementitious mass, until it is gradually removed by ordinary 
friction and ablution. Absence of comedones from the scalp, where 
the hair is vigorous, is certainly a significant fact. 

Comedones are removed artificially by the aid of an extractor. The 
instrument formerly employed for this purpose was shaped like a watch- 
key, the cylinder having a smooth bore and bevelled extremity. This 
clumsy tool is far surpassed by the exceedingly convenient comedo- 
extractor designed by Unna and modified by Piffard. Each end has 
a convex bowl-like surface, with apertures cut to gauge and the orifices 
slightly counter-sunk. This extractor is productive of far less pain to 
the patient than other instruments, and can be wielded, on account of 
its long shank, with greater precision and ease bv the physician. The 
surface to be operated upon is best previously moisteued by spraying 
it with a solution of formalin, one-half of one per cent., of borolyptol, 
of thymol and glycerin, or of eucalyptol and glycerin. Often a sharp- 
edged or well-rounded needle, firmly held in a needle-holder, may ad- 
vautageously be employed alternately with the extractor, in opening 
certain follicles or somewhat loosening the plug of others. Many 
patients affected with comedo are advantageously treated by the aid of 
the masse ring-ball, described in the chapter on the Management of 
Acne. All these instruments should scrupulously be disinfected before 
use. With the present knowledge on the subject of transmission of 
disease the danger of such manipulations should never be overlooked. 
Wigglesworth suggests the performance of the operation at night; and 
there are good reasous for selecting the hour before retiring as the time 
for all vigorous topical applications to the face. Ointments then ap¬ 
plied can be left in contact with the skin during the hours of sleep, and 
the patient be at liberty to resume his usual vocation in the daytime, 
his face being free from conspicuous evidence of local treatment. 

An ordinary watch-key, a curette, the thumb-nail, or a spatula may 


126 


DISEASES OF THE SKIN. 


also, on occasion, be used in the extraction of comedones, which, if few, 
may be removed at one sitting, or, if numerous, be removed on sepa¬ 
rate occasions. Repetition of the process is usually required owing to 
the re-formation of the plugs. 

Once the comedones are removed the skin should be sponged and 
bathed with hot water, then thoroughly dried, and anointed with an 
ointment which may be medicated to suit the indications of each case. 
Sulphur, as in all the functional disorders of the sebaceous glands, 
enjoys here also the highest reputation. In the strength of J to 1 
drachm (2.-4.) to the ounce (32.) of cold cream or vaseliu, it may be 
applied as an ointment; or as a lotion, in combination with spirits of 
wine, glycerin, etc. A useful application is suggested by Piffard— 
equal parts of sublimed sulphur, alcohol, compound tincture of lav¬ 
ender, glycerin, and camphor-water. 

Mercurials are also of some advantage locally, but, as before indi¬ 
cated, they should not be employed at the same time with preparations 
of sulphur. The use at night, especially in obstinate cases, of the 
white precipitate ointment, or of one compounded of 2 grains (0.133) 
of the red oxid to the ounce (32.) of cold cream, will often prove of 
benefit. Corrosive sublimate, 1 to 2 grains (0.066 to 0.133) to the 
ounce (32.) of glycerin and rose-water may be substituted for the red- 
oxid ointment in coarser skins. 

When the extraction of the plug is not attempted nor permitted, 
something may yet be done to remove the inspissated mass. Repeated 
sponging every third night with 1 ounce (32.) of green soap, digested 
in an equal quantity of cologne-water, will, at first certainly, seem to 
render the comedo more conspicuous, but will slowly operate to dissolve 
the sebaceous secretion. 

Unna has observed that the blackish discoloration of the comedo 
extends to a certain degree below the external extremity of the 
plug, a circumstance, in his opinion, militating against the dust-and- 
dirt theory, by which the hue of the comedo-point has been ex¬ 
plained. He concludes that this discoloration is the result of pig¬ 
mentation, such as that producing the coloration of the hair, the nails, 
and the skin in several other anomalous conditions. Having this fact 
in view, he prescribes an ointment containing four parts of kaolin, 
three of glycerin, and two of acetic acid, with or without the addition 
of a small quantity of ethereal oil. This ointment is applied at night, 
the eyes being carefully protected, for a few nights in succession, when 
the black points of the lesions are removed, and the comedones are 
then readily extracted. Citric or dilute hydrochloric acid is employed 
with the same end in view. These topical remedies cannot be consid¬ 
ered as efficient in every form of comedo. 

Actors, actresses, and women of fashion will, while under treatment, 
occasionally persist in using various colored toilet-powders, the injurious 
ingredients of which are often the cause of the disease. The practi¬ 
tioner may then either refuse to be responsible for the care of the case, 
may substitute a harmless for a noxious powder, or may gently anoint 
the face after his treatment of it with a bland ointment or the Lassar 
paste, upon the surface of which the theatrical effects are subsequently 


DISORDERS OF THE GLANDS. 


127 


produced. In such cases the use of soap and water with each dressing 
is even more than usually imperative. 

Comedones of the penis need not be treated. This injunction is 
suggested by the occasional demand made upon the physician by the 
sexual hypochondriac, who regards these lesions with a degree of alarm 
which he can best appreciate who has been confronted with a case of 
this kind. 

Prognosis. As the disease naturally tends to a spontaneous though 
occasionally a long-deferred resolution, the prognosis is favorable. 
Treatment in most cases will accomplish much in hastening the disap¬ 
pearance of the comedones. The most obstinate forms are those in 
which the face, the back of the ears, the inside of the auricle, the neck, 
and the shoulders are studded with relatively small, indolent, comedo 
points, about which the orifice of the duct rises in a whitish rim. This 
rim, when felt with the finger, produces the impression of hyperplasia 
of the wall of the duct. Such cases, however, are nearly allied to the 
forms of acne described elsewhere. With exceeding rarity, the comedo 
is merely the first step of a more serious local affection. In early 
life a single prominent lesion is formed, and though the plug be fre¬ 
quently removed and finally be no longer reproduced, the orifice of the 
duct remains patulous in middle life. Slowly thereafter its walls 
undergo a metamorphosis and a warty epithelioma may result. 


Milium. 

(Lat. milium, a millet-seed.) 

(Grutum, Strophulus Albidus, Acne Albida.) 

Symptoms. Milia occur upon and about the eyelids, the cheeks, the 
temples; the penis, scrotum, and corona glandis of men; and the 
internal face of the labia minora of women. They are millet-seed- 
to pin-head-sized, globoid masses, rarely attaining the dimensions of 
a coffee-bean, showing within the epidermis as though kernels of rice 
were lying there immediately beneath a translucent layer of tissue. 
They occasionally project from the surface to such an extent as to 
resemble small-sized vesicles having milky contents. In color they 
are yellowish and whitish. They are often congenital, and can be 
recognized about the lids and temples of the newborn infant; they 
are also seen, however, in middle life, when they develop very slowly, 
and sometimes persist for years. They are often observed in the neigh¬ 
borhood of cicatrices, which in such cases have usually been effective 
in their production. They occasion no subjective sensation, and are 
commonly so insignificant as to induce no deformity. . They never 
degenerate by ulcerative processes, but when not artificially removed 
are, in the course of years, exfoliated in the natural processes of phy¬ 
siological desquamation. 

Etiology. Milia are at times produced mechanically: the stroke of 
a knife-blade, accidentally or by the processes of surgery, separating 
one or more of the acini of a sebaceous gland from the main body. 


128 


DISEASES OF THE SKIN. 


The contracting bands of a cicatrix, after the destruction of tissue from 
any cause, may operate iu a similar way with precisely the same result. 
They may occur in connection with acne, for which in many cases no 
cause can be found. 

Pathology. When a milium is incised externally a spherical body of 
nearly corresponding size may be expressed, though it may require 
tearing from a minute pedicle below, which represents the attachment 
to the hair-f'ollicle. The small mass thus extracted is hen seen to be 
composed of several thin envelopes, suggesting the capsules of the 
onion and representing cornified epithelia which have not undergone 
fatty metamorphosis, and in the centre of which is a fatty nucleus. 
This mass represents the contents of one or more acini of a super¬ 
ficially situated sebaceous gland, cut off from the main body of the 
follicle in the manner described above, and always covered when in 
situ , as Kaposi has shown, by a delicate layer of the superimposed 
corium containing papillae. Usually the orifice of the excretory duct 
cannot be appreciated in milia, though occasionally these lesions are 
developed when the orifice is patulous. 

These singular bodies do not always represent conditions of mechan¬ 
ically pent-up sebum, as the epithelia from which their contents are 
produced seem at times indisposed to fatty transformation and are par¬ 
ticularly apt to develop into horny or other formations. Thus, Foster, 
of Boston, describes one where the process of calcification has appar¬ 
ently been complete; Wagner observed colloid contents in certain 
opalescent lesions which appeared on the cheeks and temples of a 
woman; Barensprung and Hebra report numbers of acutely produced 
milia following pemphigus aud erysipelas; and Virchow and Rind- 
fleisch describe milia of the hair-sac and similar lesions accompanied 
by cyst of the adjacent hair-follicles. It would seem rational to con¬ 
clude that, in some cases, the cause of milia is to be sought in obscure 
changes by which the epithelia of the gland are primarily affected. 

Robinson believes that milia originate from miscarried embryonic 
epithelia from a hair-follicle or from the mucous layer of the epidermis. 

Diagnosis. Milia might be mistaken for minute vesicles containing 
a milky fluid, but puncture of the lesion, with expulsion of its con¬ 
tents, at once discloses the character of each. Comedones with blackish 
external points, surrounded by the patulous orifice of the excretorv 
duct and prolonged more deeply into the substance of the skin, could 
scarcely be confounded with milia. 

The most minute of the lesions of xanthoma have a yellowish color 
and cannot as readily be scraped away from the subjacent tissue as 
can milia. 

Treatment. Milia rarely require treatment, as they are usually rela¬ 
tively few in number, and produce neither subjective sensation nor 
deformity. If desired, they may be opened with a fine milium needle, 
and their contents turned out, or they may be scraped off with the 
curette. To insure their non-recurrence, the little sac left after the 
operation may be entered with a needle dipped in a 50 per cent, solu¬ 
tion of chromic acid. This operation may have to be repeated in the 
rare cases where the lesions exhibit a special tendency to recur. 


DISORDERS OF THE GLANDS. 


129 


The simplest and most elegant method of removing these and many 
similar-sized lesions of the skin is by the galvanic battery. With from 
four to six cells in the current, the negative pole is connected with a 
fine needle which is introduced within and beneath the lesion, while 
the moistened sponge of the positive pole is in contact with the skin 
of the patient. This operation is bloodless and effectual; insignificant 
scars resulting. 

The prognosis is always favorable. 


Steatoma. 

(Gr. orkap , fat.) 

(Wen, Atheroma, Sebaceous Cyst.) 

Statistical frequency in America, 0.122. 

Symptoms. The history of the development and career of wens does 
not greatly differ from that of milia, already described. They are 
usually of slow growth; unattended by subjective sensation; occur as 
single or multiple tumors on the head, 
the trunk, or the genitals; and, being 
larger than milia, may attain the size 
of a hen’s egg. They are situated be¬ 
neath, within, or upon the skin; are 
usually unattached to the deeper con¬ 
tiguous tissues; and develop into ir¬ 
regularly globular, occasionally large 
button-shaped masses, covered by an 
integument usually unprovided with 
hairs. This envelope may be quite 
normal in hue; or unnaturally whitish 
from pressure; or, especially upon the 
bald scalp of certain fleshy men of 
middle years, reddened, shining, and 
greasy in appearance. At times the 
cysts are to be distinguished only by 
passing the fingers through the long 
hairs of the scalp beneath which they 
are hidden; at other times they are so 
conspicuous in consequence of physio¬ 
logical alopecia as to occasion considerable disfigurement. They vary 
greatly in consistency, but usually produce to the touch a certain feel¬ 
ing of elasticity, especially if the cyst be tensely distended.. They 
are rarely attacked by inflammation, resulting in suppuration and 
ulceration. 

Tumors of this kind are rarely exceedingly numerous. MacLaren’s 
patient, 1 a lad nineteen years old, exhibited tumors over the entire 



Cysts of the scalp, one of them being 
laid open to show its contents. (Gross.) 


i Brit. Med. Journ., Oct. 1886. 



130 


DISEASES OF THE SKIN. 


surface of the body; they proved on examination to be sebaceous cysts, 
but they presented all the appearances of multiple fibromata. 

Pathology. Wens represent an advanced grade of distention of the 
sebaceous glands by their contents, and a response to the constant press¬ 
ure in hypertrophy of the glandular envelope. Their contents, which 
are semi-solid, curdy, cheesy, and granular, or fluid and milky, or 
fluid and purulent, are the inspissated or chemically altered products 
of the gland-secretion, recognizable as such by the materials of which 
they are composed—masses of fat and debris of epithelia, with an 
occasional lanugo or undeveloped hair. 

In some cases wens are more than mere retention-cysts, a benign 
new-growth of connective tissue forming the mass of the tumor. 
Calcareous and atheromatous changes in the contents of the cyst are 
common. Torok, Chiari, and others claim that the majority of these 
growths are really dermoid cysts. Torok found a true papillary body 
in the walls of many of these cysts, and states, furthermore, that such 
cysts contained no fat. 

Diagnosis. Steatomata are to be distinguished from fatty tumors, 
which, however, are more commonly observed about the scapulae, loins, 
buttocks, and extremities; while wens are very rarely found except 
about the scalp and neck; they lack also the peculiar “ pillowy ” feel 
of fatty tumors. Suppurating wens in the regions named may readily 
be mistaken for circumscribed abscesses, if regard be not had for the 
history of the tumor usually long preceding. Syphilitic nodes of the 
same part are usually both tender and painful; osteomata are also 
firmly attached. 

Treatment. The removal of a wen is accomplished by excision, 
after previous puncture of the sac and the removal of its contents. 

With the antiseptic precautions observed in surgical practice to-day 
the ablation of these lesions from any part of the body may be re¬ 
garded as unattended with great risk. Several fatal cases, however, 
are on record as the result of this operation, due not so much to the 
nature of the excised tumor as to its situation, surgical wounds of 
the scalp being particularly liable to erysipelatous and other complica¬ 
tions. As the incision required for the removal of the wen must 
necessarily extend from some distance on either side of the tumor there 
results a linear scar, which on the bald scalp is often a very conspicuous 
relic of the lesion. In consequence of the possibility of danger, many 
surgeons prefer destruction of a prominent section of the mass with 
acid or alkali, leaving the sac, after expulsion of its contents, to wither 
gradually, though it may then be often withdrawn by forceps. 

Complete obliteration is sometimes effected by puncture, expression 
of the contents, and the subsequent induction of artificial inflammation 
in the walls of the cyst by injection of tincture of iodine, pure sul¬ 
phuric ether, or other irritating fluid, as in the operation for relief of 
hydrocele. 

Prognosis. The removal of the wall of the cyst is not followed 
by a return of the lesion. In debilitated and cachectic patients there 
may be spontaneous ulceration and sloughing, with or without surgical 
interference. Mr. Thomas Bryant 1 reports a carcinomatous tumor 


DISORDERS OF THE GLANDS. 


131 


following the removal of a steatoma from the buttock of a woman 
sixty-three years of age. 

Congenital Fibro-sebaceous Disease. Crocker reports two 
instances occurring in infants who at birth exhibited signs of the dis¬ 
ease, in which patches with an area of 11 several square inches 99 were 
visible on the face, the front of the neck, and in front of and above 
the ear. These patches were slightly raised, of a pale reddish-yellow 
color, finely granular over the surface, and consisted of closely aggre¬ 
gated, pale yellowish, pin-point-sized papules, the patches being sharply 
defined with many comedones at the borders. These growths, on sec¬ 
tion, seemed to be due to a fibrous hypertrophy resulting in atrophy 
of the hair-follicles and coil-glands, and separation of the lobes of the 
sebaceous glands. 

Multiple Dermoid Cysts. These occur in cases, either as few 
or more often as exceedingly numerous, uncolored or yellowish-white 
pin-head- to small-nut-sized lesions, strongly resembling multiple fibro¬ 
mata, but all containing a sebaceous or cheese-like matter when incised 
and the contents expressed. Jamieson, Hebra, Rayer, Pollitzer, 1 2 and 
others have reported these cases, the last-named observer finding a 
well-defined cyst-wall with cystic contents consisting of typical epithe¬ 
lium transformed into horny cells undergoing fatty degeneration. 

Rare Consequences of Sebaceous Cystic Disease are reported 
by a few authors, such as Cook, Hutchinson, and others, in cases where 
steatomata in typical situations have broken down into ulcerations of 
malignant type; in still other cases fungous tumors have formed of 
considerable size, requiring surgical attention. 

1 Brit. Med. Journ., May 31,1884. 

2 Amer. Journ. of Cutaneous and Genito-Urinary Diseases, Aug. 1891. 


132 


DISEASES OF THE SKIN. 


CLASS II. 

INFLAMMATIONS. 

Exanthemata. 

(Gr. e^avdTj/ua, blossoming, flowering.) 

The exanthemata are specific fevers, frequently occurring in epidemic form, com¬ 
municable by contagion, preceded by a period of incubation, and characterized 
by systemic disturbance, with an efflorescence upon the skin of different type in 
each, as also by involvement of other organs of the body, a single attack often 
conferring immunity upon an affected individual, during his or her lifetime, against 
subsequent attacks of the same disease. 

For a detailed consideration of the phenomena of the exanthematous 
fevers the reader is referred to the standard treatises on the subject 
in the field of general medicine. Brief space is allotted here merely 
to a description of the cutaneous lesions by which they are severally 
characterized. These are unlike in each disease, yet all exhibit certain 
common characteristics. In all the eruptions are symmetrical, and in 
typical cases are general. In each the efflorescence is succeeded by a 
desquamative or exfoliating condition of the skin. In each there is, 
within relatively fixed limits, a distinct stadium of the pathological 
process within which it is completed, and beyond which, however 
persistent may be its remote sequelae, there is no chronic manifestation 
of the disorder. Each, also, is produced solely by its own specific 
contagium, derived exclusively from an animal body affected with the 
same disease, being never, so far as known, generated from any other 
source, nor merging by imperceptible degrees the one into another. 
Two of these may rarely concur, but under such circumstances the one 
is always more pronounced in its features, which either closely precede 
or follow those of another. No specific medication is known to be 
capable of arresting any one of them, each pursuing its course unin¬ 
terruptedly to a favorable or a fatal termination, according to the inten¬ 
sity of the poison present in each case and the more or less favorable 
or unfavorable conditions of the sufferer. Finally, it seems probable 
that, at no distant date, specific bacteria or micrococci will be demon¬ 
strated to be etiological factors in the production of each. 


Morbilli. 

(Measles, Rubeola. Ger., Masern ; Fr., Rougeole.) 

Measles is a specific, contagious, febrile disorder accompanied by a cutaneous exan¬ 
them and an acute catarrh of the mucous surface of the respiratory tract. 

This disease is preceded by a period of incubation lasting from eight 
to twenty-one (usually from ten to twelve) days, a period in which 


INF LAMM A TIONS. 


133 


there may be no evidence of ill health, or merely a moderate degree 
of lassitude and inappetence. To this period succeeds a prodromic 
fever, the temperature rising to 103°-104° F., occasionally alternating 
with chills, or a sensation of chilliness, dryness of the skin, pains in 
the head, thirst, occasionally sweating, rarely convulsions in children, 
and, almost invariably, a serous catarrh of the mucous surfaces. By 
the second or third day the temperature begins to decline, while the 
catarrhal symptoms increase, these being manifested in sneezing, a 
copious secretion from the eyes and nose, and engorgement of the 
exposed mucous surfaces, especially of the conjunctiva, the nares, and 
the throat. Occasionally the tongue and the fauces exhibit a few 
isolated, minute, reddish puncta. In consequence of the implication 
of the larynx, the trachea, and ultimately the larger bronchi, there is 
a hoarse, frequently an incessant and teasing cough, of a convulsive 
character, accompanied by expectoration of mucus in moderate quan¬ 
tity. This prodromic period lasts from three to five days, but in excep¬ 
tional cases is prolonged to twice that length of time. Upon its 
conclusion the exanthem appears, usually on the fourth day, with 
aggravation of the fever, the temperature rising to 104°-106° F., 
and remaining at that point until the eruption has reached its apogee, 
when it commonly declines pari passu with the severity of the skin- 
symptoms. 

The eruption of measles usually appears first upon the face (the fore¬ 
head and temples), and thence extends in about thirty hours over the 
neck, the upper portion of the trunk, and the superior extremities. 
Between the fourth and the sixth day of the disease it usually attains 
its deepest shades of color, and its maximum of development over the 
entire surface of the body, including the palms and the soles. This 
maximum attained, the eruption gradually fades; the tumid condition 
of the skin, most noticeable on the face, also subsides; the catarrhal 
symptoms and cough become less annoying; and the patient enters 
upon the period of desquamation. 

The eruption is characterized by the occurrence of reddish, yellowish- 
red, mulberry-red, deep raspberry-red, or, in extreme cases, violaceous- 
tinted, small finger-nail-sized macules, either not elevated or very 
slightly raised above the general level of the integument; or by the 
occurrence of large pin-head-sized, discrete papules, much more rarely 
pin-point-sized vesicles, corresponding in color with the shades described 
above, and highly suggestive of the first efflorescence in variola. 
These lesions become pale under pressure, exhibiting then a yellowish 
tint, and are often set together very closely, particularly over the upper 
segment of the body, in patches suggesting a crescentic outline. The 
term “ suggesting ” is here used purposely, as it is difficult, by selecting 
a single patch, to determine by the eye alone the existence of such a 
configuration; while an examination of the eruption as a whole may 
often very clearly convey this impression to the sight. In other words, 
the crescentic outline is far less distinct than, for example, in certain 
of the papulo-crustaceous syphilodermata. Usually, patches of sound 
skin can be recognized, even when the eruption appears to be confluent, 
complete confluence never occurring so as to form a sheet or mask over 


134 


DISEASES OF THE SKIN. 


an entire area of the skin. Individual lesions may so merge as to be 
well-nigh indistinguishable separately; yet, ou the whole, the eruption 
deserves fully the plural character of its English name. It is made 
up in all cases of innumerable elements, whose identity is never wholly 
lost. The subjective sensation awakened is occasionally a severe itching 
or burning; frequently this is an insignificant matter compared with 
other disagreeable symptoms—the cough, coryza, and fever. 

Desquamation is accomplished usually with cessation of fever and 
the production of yellowish-brown pigmentations of the surface where 
the elements of the eruption have existed, involution being first mani¬ 
fested in the site of the lesions which were earliest to develop. Grad¬ 
ually and simultaneously the catarrhal symptoms of the respiratory 
passages diminish in severity. This final stage of the disease is usually 
terminated in a fortnight from the date of invasion. 

The complications and anomalies of measles depend upon the inten¬ 
sity of the poison, displayed in the most formidable symptoms where 
human beings are crowded together, as in camps and prisons; upon the 
degree of physical vigor; and also upon the various hygienic surround¬ 
ings of the victims of the disease. Thus, the period of efflorescence 
may be unusually prolonged; the eruption may disappear suddenly, 
and as rapidly reappear; the cutaneous symptoms may alone be want¬ 
ing; the latter may be commingled with petechise due to cutaneous 
extravasation of blood, which may also be accompanied by severe 
epistaxis; and the catarrhal condition of the mucous surfaces affected 
may terminate in croupal or in diphtheritic disease, may be followed 
by capillary bronchitis, catarrhal pneumonia, and even by pulmonary 
tuberculosis. Typhoid conditions may also supervene, and chronic 
inflammatory affections of the eyes and of the Schneiderian membrane 
result. 

The pathology of the cutaneous lesions in measles is that merely of 
acute hyperemia occasionally passing into exudation, limited for the 
most part to the vascular papillae of the corium and the perifollicular 
plexuses of blood-vessels. Post mortem the eruption fades, as the 
result of the gravity of the blood from the anterior aspect of the body 
as it reclines upon the dorsum. 

While it is possible that the cause of this disease will one day be 
demonstrated to depend upon some of the inferior organisms, no ob¬ 
server can yet claim to have conclusively established this fact. Bacteria, 
of small size and great mobility, have been found in the blood by 
Coze and Feltz; micrococci in the trachea by Klebs; spherical bodies 
in the breath of children, and, post mortem, in the lungs and liver by 
Braidwood and Vacher ; 1 and similar organisms in the vesicles and 
pustules of malignant measles by Keating and Formad . 2 

1 Braidwood and Vacher (Trans. Path. Soc. of Lond., 1878, pp. 422, 423) described sparkling staff¬ 
shaped fusiform or ovate bodies slightly tinged with carmine, which were supposed to be the 
“ micro-organisms with which the contagium of measles is intimately associated.” These organ¬ 
isms were carefully distinguished from the forms of micrococci found in inflamed tissue, though 
effects from pure culture had not been produced. It is, however, interesting to note that more 
recently Canon and Pielicke have made observations confirming in part this discovery. They 
recognized the bacilli in fourteen instances in the blood as also in secretions from the nose and 
conjunctivse, and in lung-tissue after death from measles. These organisms were cultivated with 
marked success in bouillon. 

2 See Sternberg’s Magnan’s Bacteria. New York, 1884. 


INF LA MM A TIONS. 


135 


The disease is chiefly one of infancy, probably because at that age 
there is always the largest number of individuals unprotected by pre¬ 
vious attacks. In every case the malady results from contagion, 
mediate or immediate, from an infected human subject. It spares 
neither age nor sex, though it is much rarer in advanced years than at 
other periods of life, probably because of the large number who, at 
such period, enjoy immunity. 

The diagnosis of importance is between scarlatina and variola. Typ¬ 
ical cases with a well-developed eruption can scarcely be mistaken for 
either, if the symptoms displayed are assigned their full weight. It 
would be useless, however, to deny the fact that there occur atypical 
forms, which have again and again confused the most expert diagnos¬ 
ticians; in all cases of doubt the prudent practitioner will refuse to 
decide as to the nature of the disease until the symptoms have, in the 
lapse of time, fully been declared. The resemblance between ill- 
developed measles and certain of the eruptions seen in varioloid is in 
the highest degree striking, and the greatest skill, at a given moment 
of time, will in cases utterly fail to make a decision between the two. 
A distinctly crescentic character of the eruption, the presence of 
catarrhal symptoms, the continuance of the fever after the efflorescence 
is completed, the color of the eruption, and the discovery of the nature 
of the disease from which the contagion was derived, will all point 
in the direction of the truth. From scarlatina measles is much more 
readily differentiated by the macular or papular elements of its erup¬ 
tion; by their color; by their appearance to a marked degree upon the 
face; and by the absence of the characteristic sore-throat and usually 
intense febrile access of the first-named disease. From the various 
forms of erythema accompanied by fever measles can always be dis¬ 
tinguished by the irregularity of the temperature-record, as well as by 
the character of the eruption. The distinction between rubeola and 
rotheln is given later. 

The treatment of measles should strictly be limited to careful hygienic 
attention to the invalid, including a restricted “ fever diet,” and the 
use of only such medicaments as are especially indicated. The anti¬ 
thermic remedies employed in the general management of the febrile 
process may be required in special cases. 

In the way of local treatment the skin should be anointed with a 
bland, oily, or fatty substance, to relieve the pruritic sensations, espe¬ 
cially after sponging of the surface once daily with a weak alkaline 
solution, which may be used cool without fear of producing “ repercus¬ 
sion” of the exanthem. The chamber of the invalid should be some¬ 
what darkened for the sake of the eyes, but pure air should constantly 
be admitted. 

The prognosis is, in general, favorable. All the complications named 
above increase, however, the gravity of the disease, which is also 
enhanced among men crowded together in camps, children in public 
charities, pregnant women, the cachectic and those greatly enfeebled 
from disease, very young infants, old men and women, and residents 
of islands that have long been unvisited by epidemics of the malady. 

The disease has been demonstrated to produce itself by contagion 


136 


DISEASES OF THE SKIN. 


two to four days before the appearance of the rash, while the power 
of such transmission is usually lost between the twentieth and the 
thirtieth day after the exanthem is fully developed. 


Ro'theln. 

(Rubeola, Rubella, German Measles, Hybrid Measles, 
French Measles.) 


Rotheln is a specific, feebly contagious, febrile disorder, often epidemic, accompanied 
by a characteristic exanthem. 

Symptoms. This disease has an incubative period lasting from four¬ 
teen to twenty-one days, followed either by the eruption or by brief 
prodromes lasting for a few hours to a single day. These symptoms 
are feelings of malaise, cephalalgia, articular pains, anorexia, and 
nausea. The occipital, cervical, and other glands may at this time 
become large and tender. After a pyrexic period, rarely lasting longer 
than a few hours and in many cases entirely absent, the eruption appears, 
occurring for the most part in the regions affected by measles, in the 
form of multiple, pin-point- to small pin-head-sized macules, but 
smaller than the lesions displayed in that disease, and decidedly lighter 
in color. The shade is from a rosy to a crimson-red, rarely lurid, 
never of dark mulberry or violaceous hue. This color at times will 
be perceptible beyond the line of the lesions as a delicate halo, a cir¬ 
cumstance which strongly distinguishes the exanthem from morbilli. 
The lesions, moreover, are very seldom arranged in crescentic outline, 
being more often grouped in roundish or oval patches. Often, indeed, 
the elements of the eruption are discrete and disseminated. The 
fauces are occasionally reddened in puncta. The eruption commonly 
fades in from one to two days, and there may or may not be slight 
resulting cutaneous desquamation. 

The rash of rotheln is to be distinguished from that of measles by 
the recognition of the features described above, particularly by the 
color, contour, and date of occurrence of the exanthem; the transitory 
character of the fever when the latter is present; the cervical adenop¬ 
athy; and the rapidity with which involution of the disease progresses. 
By the temperature-record alone of the patient it may be differenti¬ 
ated from scarlatina, though the rashes are dissimilar in the two dis¬ 
eases. It is also not to be confounded with the erythematous affections 
of the skin. One of the most striking characteristics of the disease 
can be best recognized in a ward filled with children, all of whom are 
simultaneously affected with the disorder. That characteristic is the 
remarkable mildness of the phenomena displayed in every case. 

After an exhaustive study of this disease Atkinson 1 concludes that 
while its characters are so defined as to justify a reasonable certainty 
in its diagnosis, it has no symptom that is not often assumed by measles. 


1 Amer. Journ. of the Med. Sci., 1887. 


INFLAMMATIONS. 


137 


Treatment. The disorder should be treated by rest in bed, a supply 
of fresh air, the strictest attention to asepsis, and the usual diet of 
fever-patients. Medication by drugs is almost never indicated. 


Scarlatina. 

(Scarlet Fever, Scarlet Rash, Canker Rash. 

Ger , Scharlach; Fr., Scarlatine.) 

Scarlatina is a specific, contagious, febrile disorder, characterized by a cutaneous 
exanthem and by involvement of the throat and other organs of the body. 

The period of incubation of scarlet fever varies between twenty-four 
hours and a month or more, the average duration being about eight 
days. The reason of this wide variation is to be sought, not in any 
changeability in the mode of evolution of the disease, but in the fact 
that its poison is less volatile and less rapidly dissipated than is that 
of measles, the result being that it may remain potential for longer 
periods in connection with articles through the medium of which it is 
transferred from one individual to another. This incubative-period, 
like that described in connection with measles, may be quite unpro¬ 
ductive of physical symptoms, or may be associated with an ill-defined 
malaise. 

The prodromes of the disease in typical cases are marked by the 
occurrence of a rapid and bounding pulse, an exceedingly dry skin, and 
a characteristic sore-throat. When examination of the mouth is made 
the tongue is seen to be thickly coated, and its filiform papillae red¬ 
dened and prominent, producing the so-called “ strawberry-tongue.” 
The velum, the pillars of the fauces, the tonsils, and all exposed 
mucous surfaces are engorged, tumid, reddened, and often covered 
with deep reddish puncta, which unquestionably represent hyperaemia 
of the perifollicular tissues. Thirst is great, and deglutition is often 
in the highest degree painful. In severe cases the mucous surfaces 
named may speedily exhibit finger-nail- to pigeon-egg-sized, ashy 
ulcerations with a lurid halo at the periphery. In children there may 
be syncope, delirium, convulsions, vomiting, or, when the poison has 
been intense, fatal results from shock of the nervous centres. This 
prodromal period usually lasts from twelve to twenty-four hours, 
though it may be prolonged for two- days more. In this respect scar¬ 
latina is markedly distinguished from measles. This stage is termi¬ 
nated by the appearance of the exanthem, but the fever persists without 
abatement after the explosion; and thq other symptoms of the disease 
are then in no wise ameliorated. 

The eruption in scarlatina usually spares the face, however much 
the latter may display two damask-colored cheeks under the febrile 
flush, may become tumid with the acceleration to it of the blood pumped 
through the throbbing carotids, or even may exhibit a few scanty 
lesions upon the forehead and temples. About the mouth the integu¬ 
ment is always pallid; this is far different from the picture presented 
in measles. The eruption is first seen in the form of light or deep red, 


138 


DISEASES OF THE SKIN. 


pin-head-sized puncta, so closely agglomerated as to produce upon the 
eye the impression of a diffuse reddish blush. It is first seen about 
the neck and the clavicular regions, but it rapidly spreads to the trunk 
and extremities, including the dorsal surfaces of the hands and feet, 
attaining complete development in the course of the second day of the 
eruption. It is then of a distinctly scarlet color, whence the disease 
derives its name in Latin, English, and German, a coloration frequently 
compared with the appearance of a boiled lobster. Upon the limbs 
it is often developed in punctate form, while the occurrence of a diffuse 
scarlet blush is most distinctly perceived by the eye in the examination 
of the trunk, where the rash is seen to fade under pressure. The 
finger-nail drawn rapidly over the surface of the skin is followed 
by the formation of a whitish line, which persists for an instant, a time 
sufficient to enable one to describe a letter upon the skin. This period 
of efflorescence lasts from one to two days to an entire week, during 
which, as stated above, the febrile and other symptoms continue 
unabated. 

The rash usually persists at its maximum of development from one 
to three days, the concomitant symptoms continuing without noticeable 
abatement. Among the latter may be named the occurrence of albu¬ 
min in a urinary secretion of diminished specific gravity, with occa¬ 
sionally the presence of epithelium, recognizable under the microscope 
as derived from the lining membrane of the uriniferous tubules of the 
kidney. 

Having attained its apogee, the eruption in favorable cases begins 
to fade, the part first affected exhibiting earliest a lighter shade, while 
the other pathological phenomena diminish in severity, the sore-throat, 
especially in ulcerated conditions, alone persisting. In from four to 
ten days longer the eruption disappears, leaving a brownish-yellow pig- 
mentation of the skin-surface; simultaneously the other symptoms of 
disease vanish. 

The desquamation which then ensues, as convalescence progresses, is 
general and is often proportioned in extent to the severity of the pre¬ 
ceding eruption, though it may be generalized after a well-nigh imper¬ 
ceptible exanthem. Desquamation is more pronounced and characteristic 
in scarlatina than in any other of the eruptive fevers. It may be super¬ 
ficial and furfuraceous in character, or the epidermis may fall in 1am- 
ellated layers, for example, the sheath of an entire finger, with the 
nail, or that of the entire palm. In this way sheets, ribbons, and 
shreds of the horny layer of the skin may fall from its surface and 
expose, beneath, a new and often tender epidermis. The hairs mav 
simultaneously be shed. When this desquamation is finished the 
stadium of the disease may be regarded as concluded, the entire period 
lasting in uncomplicated cases from a fortnight to a month or six weeks. 

The complications, anomalies, and remote sequels of scarlatina are 
so numerous as to furnish a vast array of facts for the study of the 
pathologist. The reader need merely be reminded in these pages that 
the usual incubative and prodromic stages of the disease may be brief 
as to time,, or be so brusquely followed by eruptive phenomena as to be 
indistinguishable. The latter may also first occur upon the extremities 


INF LAMM A TIONS. 


139 


01 trunk, and later on the neck and over the clavicles; or at once cover 
the totality of the surface by a rapid explosion, or be extremely short¬ 
lived, or be altogether absent, or be unusually prolonged and visible 
for even a fortnight upon the surface of the body, appearing and well- 
nigh disappearing without appreciable cause. To a proportionate ex¬ 
tent the stage of desquamation may precociously or tardily be reached, 
and the exfoliating process tediously be prolonged and of intense type, 
jeoparding in this manner the future of the convalescent prostrated by 
the fever which has passed or the sympathetic fever which may thus be 
awakened. 

The anomalies of the scarlatinal rash are numerous, but they depend, 
in general, less upon a variation in the intensity of the poison than 
upon the physical condition of the patient. Thus, the affected surface 
may be elevated slightly above the general level; there may be no 
coincident pyrexia; the skin may exhibit irregularly disposed mottlings 
and maculations, may be characterized by the occurrence of miliary 
papules, minute vesicles, or purpuric lesions, well defined against the 
general scarlet color of the skin by their violaceous shade and due to 
cutaneous extravasation of blood. The rare bullous, pustular, and 
urticarial lesions which may appear upon the skin are accidental and 
bear no relation to the specific history of the disease. 

Malignant anginose scarlatina is characterized by the gravity of the 
throat-symptoms. In such cases a parenchymatous inflammation of 
the tonsils, velum, and fauces supervenes at an early period, with 
enormous tumefaction; involvement of the submucous tissue and neigh¬ 
boring glands; and ulcerative, suppurative, and even gangrenous results 
which speedily prove fatal. Gastro-intestinal disorders may also prove 
dangerous. An otitis externa, media, or interna may perforate the 
tympanum, destroy the ossicles, induce caries of the mastoid process 
of the temporal bone, and prove fatal by the eventual production of 
meningitis or phlebitis. 

Another severe type of this disease is that in which symptoms of 
typhus are pronounced (Scarlatiniform Typhus). Here the patient 
may perish within a few hours after being attacked and before the 
eruption appears, exhibiting comatose or convulsive symptoms, indicat¬ 
ing the profound influence upon the nervous centres of the intensely 
intoxicated blood; or the eruption may have time to appear, often 
livid, hemorrhagic or petechial in type, and be followed by albumin¬ 
uria, meningitis, diarrhea, coma, and death. Catarrhal and paren¬ 
chymatous nephritis is justly dreaded during the desquamative period 
of the malady, when it may prove fatal after a relatively benignant 
manifestation of the disease in its prodromal and eruptive stages. 
To this sufficiently grave list of disorders which may complicate scarlet 
fever must be added pneumonia, pericarditis, pleuritis, peritonitis, 
chronic purulent nasal catarrh, which may result in caries of the nasal 
bones, destruction of the cornea as a result of severe keratitis, per¬ 
sistent adenopathy of the subcutaneous glands, and malnutrition in 
many forms, which may so impair the vigor of the constitution as to 
leave the sufferer a physical wreck for the remainder of life. 

The cutaneous lesions of scarlatina, like those of measles, depend 


140 


DISEASES OF THE SKIN. 


upon hyperemia and a moderate degree of exudation. The latter, 
when it occurs, is limited for the most part to the rete and papil¬ 
lary layer of the corium. The signs of the disorder are not appar¬ 
ent in the dead body unless there have been exudation of blood and 
the consequent formation of petechiae. 

Etiology. The disease is produced exclusively by contagion derived 
from the animal body affected with scarlatina, either mediately or 
immediately. It attacks individuals of both sexes and all ages, chil¬ 
dren and infants more frequently, the aged more rarely, probably in 
consequence of their respective conditions as regards immunity con¬ 
ferred by a previous attack, since, in general, the disease occurs but 


Fig. 37. 



Microphotograph of the edge of a small colony of the bacillus scarlatinae : 
a. Central zone. b. Outer edge of growth. 


once in a lifetime. Individual idiosyncrasy must acccount for the 
cases in which unprotected infants exposed to the disease fail to receive 
it, a fact noted occasionally in all the exanthemata. The contagious 
element, which is volatile in its nature, seems to be most active during 
the eruptive stage of the disease. 

Rod-like bodies and mobile points have been found by Reiss, Coze, 
and Feltz in the blood of patients affected with scarlet fever; and 
injection of rabbits with such blood has proved fatal. Jameson and 
Edington 1 have recognized and cultivated the u bacillus scarlatinse,” 
which measured OAg in thickness and 1.2 to lAg in length, and formed 
long, jointed, and curved, motile leptothrix filaments. Exceedingly 
interesting clinical facts as to the transmission of scarlatina through 


1 British Medical Journal, June 11,1887, and August 6, 1887. 


INF LAMM A TIONS. 


141 


the medium of the milk of diseased cows have been set forth by 
some of the local health boards in Great Britain. Scarlatina at times 
follows injuries and surgical operations, due, as Atkinson supposes, 1 
to diminished powers of resistance to the disease. 

The diagnosis is between measles, rotheln, erysipelas, and the erythe- 
mata, and, in general, is readily established. The sore-throat, intense 
fever, punctiform scarlet rash reaching to the border of the inferior 
maxilla, and the distinct, whitish-yellow line traceable by the finger¬ 
nail when passed rapidly over the surface, are all characteristic. In 
measles the macular character of the rash, and its cresoentic arrange¬ 
ment, in connection with the catarrhal symptoms, will usually be recog¬ 
nized. From erysipelas scarlatina can always be distinguished by 
the absence of the peculiar, shining, smooth, or glazed and tumid 
condition of the affected area. From all other rashes scarlet fever 
can be distinguished by the pyrexic symptoms and resulting desqua¬ 
mation. 

Great care should be taken not to confound the drug-rashes having 
a scarlatiniform appearance with the specific disease under considera¬ 
tion. Thus, belladonna, in doses of 1 minim of the tincture every 
hour to the extent of four doses, has produced an abundant scarlatini¬ 
form eruption in children, a diagnostic point of importance in view of 
the fact that the drug named is employed popularly as a prophylactic 
against the disease. For the medicinal eruption of this sort due to 
quinin and other drugs, the reader is referred to the pages devoted to 
Dermatitis Medicamentosa. 

Treatment. The modern treatment of uncomplicated scarlatina is 
antiseptic and expectant, after provision is made for an abundant supply 
of fresh air, disinfection, a proper regulation of food and drink, and 
the local use of baths, tepid or cool, for the purpose of reducing the 
body-temperature. After each of these baths the skin should be com¬ 
pletely anointed with a fatty substance, such as cold cream, scented 
almond or olive oil, or, what is more commonly used in America, with 
vaselin. These inunctions are not only grateful to the patient, but 
they reduce the body-temperature to a slight degree. All treatment, 
other than that suggested above, pertains to the field of general medi¬ 
cine, and should be limited to the special conditions presented in each 
case. Such treatment includes the management of disorders of the 
eye, ear, throat, kidneys, and other viscera, the involvement of which 
constitutes a complication of the disease. 

The prognosis of the malady should always be established with 
reserve . It is largely based upon the relative intensity of the symp¬ 
toms, the vigor and age of the subject, and the presence or the absence 
of serious complications. Albuminuria is rarely absent, and not per se 
alarming; but anasarca and other evidences of profound interference 
with the renal function are to be assigned due weight. In general, 
it may be said that a high range of temperature; early and ulcerative 
throat-lesions; tardy development, rapid and untimely disappearance, 
or undue prolongation of the exanthem; and its admixture with 

1 Journal of Cutaneous and Venereal Diseases, vol. iv., October, 1886. 


142 


DISEASES OF THE SKIN. 


petechise to such an extent as to indicate extensive hemorrhagic extrav¬ 
asation, are all formidable symptoms. Finally, it must not be for¬ 
gotten that the mildest and simplest forms of the disease, after the 
fastigium is passed and convalescence is actually established, may 
terminate fatally by the supervention of ursemia, cerebral paralysis, or 
even meningitis, consequent upon secondary changes in the middle 
or internal ear. 


Variola. 

(Lat. varus, a blotch.) * 

(Small-pox. Ger. f Blattern, Pooken; Fr., Petite V£role.) 

Variola is a specific, contagious, and febrile disorder, characterized, when unmodified, 
by the appearance in succession upon the cutaneous surface, and occasionally also 
upon the mucous surfaces, of papules, vesicles, pustules, crusts, and cicatrices. 

The variations of variola as to the severity, character, and duration 
of its symptoms are so great as to preclude complete description of 
this malady within the limits here assigned. The following paragraphs 
are therefore devoted to a brief sketch merely of its more commonly 
recognized characters. 

Symptoms . The period of incubation of the unmitigated disease 
varies between ten and twenty days, occupying usually a fortnight. 
It is characterized by the peculiarities of that period recognized in all 
the exanthemata, there being few and insignificant or no evidences of 
physical discomfort. The prodromic stage is ushered in generally by 
a vespertine chill, succeeded by fever, with a temperature rising to 
104°-106° F., which is commonly associated with severe and charac¬ 
teristic pain in the loins, headache, nausea or vomiting, and occasion¬ 
ally in young subjects, delirium and convulsions. The fever continues, 
with alternations of exacerbations and partial relief, or sensations of 
chilliness, on the second and third days. At the same time there may 
be faucial hyperemia and moderate dysphagia. Occasionally, before 
the cutaneous exanthem appears, minute reddish papules may be 
recognized upon the buccal membrane. 

On the second and third days there appears, in some cases, especially 
in menstruating women and in young subjects, a cutaneous efflorescence, 
whose significance has often been misinterpreted, thus leading to many 
errors in diagnosis. To Hebra we are indebted for its distinct recog¬ 
nition as a cutaneous prodrome in variola. It has been termed Vari¬ 
olous Erythema and Variolous Roseola. The recognition of 
this erythema is a matter of special importance to the diagnostician, as 
many have been deceived respecting its nature and significance. It is 
characterized by the occurrence of irregularly disposed and distinctly 
outlined maculations, puncta, stria?, streaks, or a diffuse blush of bright 
or lurid reddish hue; the invaded integument being at times slightly 
tumid, and thus elevated above the general level. The affected part 
may also be the seat of moderate pruritus. The blush may fade under 
pressure, but rarely does so perfectly. One cannot by the finger pro- 


INF LAMM A TIONS. 


143 


duce upon it a visible whitish spot. The rash occurs most often about 
the groins, the hypogastric region, the pubes, and the inner faces of 
the thighs, and on examining these parts the physician will usually 
discover the evidence, in adult women, of recent or present menstrua¬ 
tion, or of the puerperal state. It occurs also about the axillae, the 
extensor faces of the larger and smaller joints, and the lumbar and 
clavicular regions. Often a broad area of the integument in these parts 
may exhibit a sheet or mask of dull crimson erythema, upon which may 
form pin-head- to bean-sized, dull reddish papules, not losing their 
color under pressure, or more rarely petechiae, vesicles, and wheals. 
All these are precursory phenomena, and are not transformed into 
characteristic variolous lesions. They fade almost completely before 
the latter appear. Rarely, a few scattered papules may be distinguished 
upon the face and the arms before the variolous erythema fades. Often 
the papules in full development are even less profusely displayed in 
the site of the precedent efflorescence. The latter need not be neces¬ 
sarily regarded as a symptom of portentous gravity. The author has 
seen the entire surface of the belly covered with a uniform erythema¬ 
tous blush of dull crimson hue, followed by confluent variola, and the 
patient ultimately recover. The physician, then, in the face of a deep- 
red erythema of the regions named, especially of the groins, the lower 
part of the belly, and the thighs of a menstruating woman affected 
with high fever, nausea, vomiting, and lumbar pain, should invariably 
suspect the presence of variola. 

Fig. 38. 



Vertical section of pustule at the beginning of pustulation: a, umbilication at the site of an 
excretory canal; b, reticulum within the epidermis; c, reticulum ot smaller meshes containing 
lymph- and pus-globules. (After Rindfleisch.) 

The period of eruption is characterized, at its earliest, by puncti- 
form, subcutaneous discolorations which photography alone can reveal. 
Commonly, after three days of prodromic symptoms, the patient will 
be seen on the morning of the fourth day with the face and scalp 
covered by pin-head-sized and larger, firm, conical papules, whose 
touch to the finger is compared by most English writers to the feeling 




144 


DISEASES OF THE SKIN. 


of shot. Later, these papules develop upon the trunk and limbs; and 
in well-marked cases every portion of the body-surface is invaded, 
including the palms and soles. The lesions may be surrounded by a 
narrow rosy areola upon the trunk. They may be unproductive of 
subjective sensations, or be slightly tender. 

As a rule, there is complete defervescence when the exanthem ap¬ 
pears, the patient experiencing such relief that if an adult has chanced 
not to view his face in a mirror nor to be informed of his appearance 
by those in attendance upon him, he will often regard himself as com¬ 
pletely relieved of his three days’ illness. In other cases the febrile 
symptoms persist, with a lowered temperature. 

During the first two days of the eruptive period the papules increase 
in number and become correspondingly agglomerated; while those of 
earliest appearance become transformed into vesicles containing a trans¬ 
lucent serum, the roof-wall of many of them exhibiting an umbilica- 
tion. This umbilication of the vesicle is characteristic, and slightly 
different from that observed in bullous and pustular lesions. The 
central depression is disproportionately large, and about it the yet 
undistended epidermis is often irregularly puckered or fluted. Even 
in this period the lapse of a few hours will produce a lactescent appear¬ 
ance in the formerly translucent contents. 

From the eighth to the twelfth day the transformation of these 
lesions into pustules is effected, the process beginning, as in all the 
metamorphoses of the disease, in the vesicles of greatest age: those, 
namely, on the face and upper portions of the body. The lesions 
simultaneously enlarge until they are of the size of an average-sized 
pea, and, being fully distended, rupture the centrally placed filament 
which held down the roof-wall, consequently the umbilication of the 
pustules is lost. With this process of suppuration is awakened the 
so-called “secondary fever,” a pathological process evidently not 
essential to the disease, as it does not occur in mitigated cases. This 
secondary fever is bom of the extensive process of suppuration occur¬ 
ring in the skin and other organs, and may be symptomatic, sympa¬ 
thetic, or septicemic in character. It thus varies in different cases 
with the character and severity of the process by which it is excited, 
being transitory in mild cases, and in others terminating only with 
death. At this time the patient is usually in a most distressing con¬ 
dition. The skin of the face and of other attacked regions is swollen, 
thickly covered with pustules, and the features indistinguishable in the 
tumid and closed lids, the oedematous lips, disfigured nostrils, and pus- 
obstructed mucous outlets. Deglutition becomes painful and often 
impossible, the saliva flows from the lips, and the mucus of the nares 
dries with the pus upon the exterior of the visage. The pustules 
recognized upon the integument are represented also in the gastro¬ 
intestinal tract. In an autopsy of a patient dead at this stage of the 
disease we discovered the entire canal from the mouth to the anus, as 
also the genito-urinary and respiratory passages, completely covered 
with closely agglomerated and well-distended pustules. The career 
of those within the mouth can usually be studied by eye-observation. 
In this situation they rapidly lose their epithelial roof-wall by reason 


INF LAMM A TIONS. 


145 


of the heat, moisture, and friction to which they are subjected, and 
then exhibit a reddened and excoriated surface, over which there is 
re-formation of the epidermal layer. Gangrenous complications are 
rare. 

Between the thirteenth and the fourteenth days desiccation begins, 
and is usually completed within from ten days to a fortnight after¬ 
ward; the pustules rupture, and the exuded pus concretes into yellowish 
or brownish, rarely blackish crusts, or the latter are formed by the 
desiccation of. the entire envelope and contents. The pulse usually 
at the same time diminishes in frequency, a secondary defervescence 
occurs, the tumefaction of the integument decreases, and at times the 
peculiarly characteristic, and often intolerably fetid odor from the 
patient is less perceptibly exhaled. In from four to six weeks the 
course of the disease is completed. The immediate traces of the erup¬ 
tion are purplish and violaceous pigmentations, which slowly disap¬ 
pear. When cicatrices result they are slightly depressed, dead-white, 


Fig. 39. 



Vertical section of one-half of an undeveloped pustule: a, old epidermis ; b, epithelia of rete 
above the alveoli; c, a new-formed epidermis ; d, alveoli filled with pus-globules; g, flattened 
and infiltrated papillae lying beneath the pustule. (After Auspitz and Basch.) 

lustrous, usually symmetrical in disposition, and most distinct upon 
the surfaces exposed to the light and air, such as the face. Though 
persistent, they are rendered somewhat less deforming in the progress 
of years. When closely set together they produce a characteristic 
ridged and corded appearance, due to the elevation of narrow bands 
of unaffected integument between the depressed surfaces of scars. The 
several departures from the pronounced type of the disease described 
above present variations differing widely from the most benignant 
forms. Brief reference only can be made to these variations. 

Varioloid, whether occurring after vaccination or not, is a modified 
form of variola. With it should be classed all those forms of the dis¬ 
order occurring in the human subject, and described by authors under 

10 





146 


DISEASES OF THE SKIN. 


the titles of u swine-pox/ ’ “ horn-pox,” etc. In these cases there may 
be a severe prodromic fever and a scantily developed exanthem; rapid 
involution of lesions; abortion of the latter in any of their several 
stages from papule to crust; absence of secondary fever; transmission 
of the disease in a mild or mitigated form, from one individual to 
another, so that an entire community, vaccinated and unvaccinated 
alike, may suffer from an epidemic disorder of this moderate grade 
without the occurrence among them of a single case of typical variola. 
It is scarcely necessary to add that the patient with varioloid, especially 
during an epidemic, may transmit to the unprotected a malignant 
form of the disease. 

Much more formidable, viewed from every standpoint, is Hemor¬ 
rhagic Variola, fortunately rare and too often confounded in the 
past with “ black measles.” When cutaneous hemorrhages occur 
during the course of small-pox they do not necessarily indicate that 
the case is one of so-called “ varioliform purpura,” since these may be 
accidents of the pathological process. In this malignant form of the 
disease, against the ravages of which vaccination often presents a feeble 
barrier, the prodromic stage is followed by a deep purplish redness of 
the surface which is characterized by pin-head- to split-pea-sized, firm, 
closely set, papular lesions, suggesting the occurrence of measles in a 
peculiarly severe form. The febrile, nervous, and other symptoms of 
the disease are proportionately intense. Eccliymoses appear upon the 
conjunctival membrane. Gradually the color of the exanthem, that 
at first disappeared under pressure, refuses thus to yield and assumes 
a bluish-black shade. Ecchymotic patches may be intermingled with 
the papules, rapidly widening to palm-sized and larger areas. The 
mucous surfaces share in these colors, being also infiltrated with effused 
blood, and the muco-cutaneous orifices are crust-covered and exhale 
an extreme fetor. Blood may escape from the bowels, bladder, mouth, 
and vagina. Signs of grave systemic and visceral complications are 
always present. Vesiculation, pustulation, and the typical trans¬ 
formations of variolous lesions are all wanting. In the few cases 
observed by the author death has always speedily supervened, either 
from shock, coma, hemorrhagic infarction of the lungs, or rapid ex¬ 
haustion. Intermediate forms between hemorrhagic and true variola 
are described, in which forms the pustules occurring in the variolous 
type of the disease merely fill with blood in consequence of accidents 
possessing a purely local significance. 

Confluent Variola is another severe form, less malignant, how¬ 
ever, than that just described. It is characterized by intensity of the 
prodromic fever, which often scarcely abates with the appearance of 
the exanthem. The latter is developed in deeply implanted, firm pap¬ 
ules, closely set together, succeeded by vesicles and pustules, which, 
as they enlarge, fully occupy the entire surface of the integument, and 
accomplish a perfect coalescence. In well-marked cases there is scarcely 
a pin-head-sized area of the entire surface of the body that is not 
invaded. The tissues become enormously oedematous; the deformity 


INFLAMMA TIONS. 


147 


of the face renders the features indistinguishable. Hemorrhagic pus¬ 
tules and even patches of a gangrenous pulp may be intermingled with 
sheets of suppurating surface. Phonation, respiration, and degluti- 
tition are proportionately impeded or are absolutely subverted by the 
tumefaction and suppuration of the mucous membranes of the respira¬ 
tory and gastro-intestinal tracts. When the patient survives until the 
stage of desiccation is reached the body presents an aspect as revolt¬ 
ing as that ever displayed by a living being. A thick, brownish or 
blackish-brown mask envelops the swollen head, trunk, and limbs, 
and the odor exhaled from the body is intolerably repulsive. All the 
systemic phenomena are proportionately grave, and are accompanied by 
one or more of the complications of the malady—pneumonia, pleuro¬ 
pneumonia, albuminuria, diarrhea, various motor and sensory paral¬ 
yses, subcutaneous furuncles, and abscesses. The eyes may suffer from 
pustular and ulcerative changes in the conjunctiva, cornea, and deeper 
tissues, Avitli resulting inflammation of every grade to pan ophthalmia, 
and resulting loss of vision. Often the patients, with surprising powers 
of resistance, will survive until extensive sheets of crusts have fallen 
from the skin-surface, and then perish slowly in a typhoid condition 
with low remittent or continuous fever. Every such case does not, 
however, terminate fatally. Children may rally from the severest form 
of confluent variola, and afterward eujoy vigorous health, thus illus¬ 
trating well the wonderful recuperative energy of the natural forces 
under the most adverse circumstances. 

Etiology. Variola is always the result of mediate or immediate 
contagion. It is a disease both contagious and infectious, being trans¬ 
missible by volatile emanations from the victims of the disease. It is 
also artificially inoculable. When transmitted by the latter process 
its period of incubation is somewhat shortened, and often its successive 
manifestations become less formidable. The history of inoculated 
human variola has, however, received but little attention during late 
years, since the practice has properly been forbidden by law. The 
disease is, to a certain extent, transmissible from man to the lower 
animals, and the reverse. It attacks individuals of both sexes and all 
ages, including the foetus in utero , which may be ushered at an untimely 
hour into the world, macerated or recently dead and covered Avith the 
lesions of variola. The disease in the larger cities is decidedly more 
frequent in Avinter than in summer, possibly because in the colder 
months the opportunities are greater for spreading the contagion in 
artificially heated dAvellings Avhere numbers of individuals are crowded 
together. Islanders, long unvisited by an epidemic and unprotected 
by vaccination, may suffer equally in the summer season. 

The parasitic nature of variola has not been demonstrated. Coze, 
Feltz, Baudouin, Luginbiihl, Weigert, Hallier, and Cohn have recog¬ 
nized micro-organisms, both bacteria and micrococci, in the blood of 
variolous patients. None of these organisms has yet been utilized in 
the production of the disease; but Cohn 1 regards these parasites as a 


i See Magnan, loc. cit., p. 411. 


148 


DISEASES OF THE SKIN. 


twin race of the micrococcus vaccinse discovered in vaccine-lymph. 
The secondary fever of the disease is without question septicemic and 
is due to pus-cocci aud their toxin. 

Diagnosis . The difficulty attending the diagnosis of variola in its 
prodromic and earliest eruptive stages, from measles, is considered in 
the description of the latter disease. The general demand, indeed, 
upon the physician for an exact and definite diagnosis of every case 
before its complete evolution, is founded upon an erroneous concep¬ 
tion of possibilities, and the sooner this is generally recognized the 
better for all concerned. A delay of even a few hours will often verify 
or remove a suspicion, and the author is confident that he has seen 
fully as much mortification on the part of the physician and damage 
to the best interests of the patient result from an error in one direction 
as in the other. The wisest course in every doubtful case is to admit 
the doubt and to visit the patient frequently for the purpose of observ¬ 
ing the development of the disease until that doubt is removed. Typ¬ 
ical cases of variola are recognized with ease from the character of the 
symptoms presented. Syphilis and acne are always distinguished by 
the absence of fever and their relative chronicity. 

The prognosis of variola is largely dependent upon the degree of 
protection conferred by previous vaccination. Independent of vacci¬ 
nation, the age and vigor of the patient, the presence or absence of an 
epidemic of severe or mild type, the extent of the eruption, and the 
character of the surroundings of the patient, are elements of prime 
importance. Very young and aged subjects, women pregnant or in 
the puerperal state, and, as Hebra has shown, those who have suffered 
from a previous attack of the same disorder, are all unfavorably 
disposed to the final result. Confluent and hemorrhagic forms of 
the disease are, naturally, the gravest. Unmitigated variola, under 
the most favorable circumstances, is one of the greatest scourges of 
humanity, and as such will probably always destroy a frightful propor¬ 
tion of its victims. At the same time the conscientious physician needs 
to be impressed with the fact that, under the most discouraging circum¬ 
stances, the patient, disfigured to the greatest extent by an envelope of 
blackened crust, and in a state of extreme physical prostration, with 
many of his bodily functions almost completely suspended, may even 
from the midst of such peril be won back to life and vigor. The 
assiduous attentions of a gentle nurse, guided by the inspiring presence 
and counsels of a physician who is himself fearless of the malady, will 
often achieve the result. Upon the latter point it is interesting to 
note that physicians iu active practice who do not hesitate to expose 
themselves freely to the disease in the discharge of the duties of their 
profession, rarely suffer in their own persons. 

The treatment of variola should, in general, be limited to the indica¬ 
tions presented in each case. No remedies can be employed which 
have the least power to abort the disease. Kaposi calls attention to 
the striking fact in this connection, that syphilis, for many of the mani¬ 
festations of which mercury is a specific, is a disease whose second 
incubative period is measured by weeks, and yet neither by excision of 
its initial sclerosis nor by mercurials can the subsequent manifestations 


INF LAMM A TIONS . 


149 


of the disease be completely prevented. Certainly, no specifics are 
recognized as of value in variola. The patient should be kept in 
a relatively dark room with an abundant supply of fresh air of a 
uniform temperature, and antiseptic solutions should constantly be at 
hand into which all the ejecta are immediately received. He should 
be given ice when this is acceptable to the palate, cool water ad libitum, 
and his strength should sedulously be supported by a liquid animal 
diet. The body may be sponged with or bathed in cool or in tepid 
water, as often as is grateful to the patient. In severe or confluent 
cases the constant immersion of the body in the continuous warm- 
water bath, as practised in Vienna, is followed by the most brilliant 
results in hastening the desiccation and fall of the crusts and sub¬ 
sequent repair. A bath of this character given for merely two or three 
hours in the day is often of great value. With and without these 
external measures gargles of chlorate of potash, myrrh, honey, or 
carbolic acid will be found acceptable to the mouth and palate. 
Indeed, the constant attention of an efficient nurse bestowing assiduous 
care upon the mouth, the skin, and the eyes may be regarded as an 
essential part of all sound treatment. 

As regards the prevention of pitting, it may be remarked that no 
measures of a therapeutic character will prevent the occurrence of a 
distinct cicatrix whenever pus has eroded or otherwise destroyed the 
integrity of the papillary layer of the corium. Every effort, therefore, 
should be exerted to prevent the extension of the suppurative process 
to the true skin. The following are measures which have approved 
themselves as of practical value : First, the sick-room should be mod¬ 
erately darkened, and yet be amply provided with fresh air. Second, 
a solution of the hyposulphite of sodium (Squibb’s is superior to the 
ordinary preparations in the market) should be administered night and 
day in the dose of from 15 to 20 grains (1.-1.3) every three or four 
hours. Certainly the variolous lesions pursue a milder course under this 
internal treatment, and, in some cases, even the vesicles shrivel before 
pustulation is fairly begun. Third, the skin of the face should be 
anointed with a bland fatty substance such as vaselin, almond oil, or 
fresh lard, and over the unguent may be laid silk-enveloped compresses, 
dipped in tepid, weak solutions of carbolic or of boric acid, or of 
thymol. The anointing of the surface before the application of the lotion 
is commonly more grateful to the patient, but the skin may constantly 
be moistened with the aqueous lotion alone. Here, again, the assid¬ 
uous attention of the nurse is a matter of importance. The powder 
of iodoform topically is often applied with advantage. 

The edges of the eyelids should daily be anointed with freshly pre¬ 
pared cold cream. Puncture of the cornea may be required for the 
relief of hypopyon. Diarrhea and other symptoms of visceral de¬ 
rangement should be relieved by appropriate medication. As a 
rule, the administration of narcotics for the relief of pain is objec¬ 
tionable. Throughout the course of the disease the strength of the 
sufferer should be supported by a generous use of animal broths or of 
milk; in typhoid conditions a judicious employment of stimulants may 
be necessary. 


150 


DISEASES OF THE SKIN. 


Varicella. 

(Chicken-pox. Ger. f Spitzblattern ; Fr. , Variolette.) 

Varicella is a contagious, febrile disorder of benignant and mild character, accom¬ 
panied by a vesicular exanthem. 

Symptoms. This disease has an incubative period lasting for about 
a fortnight, after which there is occurrence of malaise, chilliness, and 
languor. The patients are usually children, who may suffer thus from 
fever of a moderate grade lasting from a few hours to two or three days, 
after which defervescence is commonly complete. With the onset of the 
fever, or even without, the rash appears, first on the head and trunk, in 
the form of rosy macules or slightly elevated lesions lacking the charac¬ 
teristic “ shot-iike” feeling of the variolous papule. These macules 
rapidly become vesicular, the lesions being pin-head- to pea-sized, limpid, 
superficial in situation, differently shaped from variolous lesions, and 
very rarely umbilicated, puckered, or “ fluted ” as in small-pox. The 
macules appear in successive crops, and are often surrounded by a faint 
halo. Their contents become cloudy or lactescent rather than puriform, 
and they desiccate as early as the second day, forming thin, light, 
superficial crusts. The lesions may be abundant in one region, as, for 
example, over the back or the chest, but are practically never both 
abundant and generalized, and never confluent. Like variolous lesions, 
they extend at times to the mucous surfaces of the eyes, the mouth, and 
the genital regions. Occasionally they are productive of pruritic sen¬ 
sations. Often the course of the disease is so mild and the exanthem 
so slight as scarcely to attract attention Cicatrices result only in 
places, chiefly the face, where the lesions have been subjected to local 
irritation. 

Diagnosis. It is well kuown that a number of German authorities, 
following Hebra, have given assent to the doctrine taught by the latter 
that varicella is only a mitigated form of variola. That doctrine is 
offensive to American and English physicians, who in practice find it 
vastly wiser to distinguish carefully and exactly between the diseases 
in question. The settlement of the discussion may well be relegated 
to a date when the probable parasitic nature of both disorders can 
exactly be determined. 

In variola the invasion-period of relatively fixed limits, the speedy 
transformation of the lesions into minute, firm papules, their early 
appearance on the exposed parts of the face and wrists, the age of the 
patient, the thermic variations, the prodromic rashes, and the speedy 
transformation of the papules into umbilicated vesicles, are all impor¬ 
tant diagnostic points. In varicella, the trunk usually exhibits the 
greater number of lesions, which appear also in successive crops. 
Beside the characteristics of the cutaneous lesions the catarrhal symp¬ 
toms of measles and the sore throat of scarlatina will point to the 
nature of these disorders. Impetigo contagiosa is to be very care¬ 
fully distinguished from varicella, since the two affections occur at 


INFLAMMA TIONS. 


151 


times side by side in one hospital ward, and occasionally the former 
succeeds the latter. The lesions of impetigo contagiosa are often 
larger, generally more persistent, and the crusts bulkier than in vari¬ 
cella, and the patients may be of a more advanced age. 


Vaccinia. 

(Cow-pox. Ger., Kuhpocken; Fr ., Vaccine.) 

Vaccinia is a specific bovine fever, accompanied by a vesicular exanthem, transmis¬ 
sible to man by inoculation. 

The limits of this volume forbid a discussion of the interesting ques¬ 
tions concerning the relations of cow-pox as it occurs spontaneously in 
the milch-cow, to human variola. A careful collation of the results 
obtained by the large number of vaccini-culturists of recent days ren¬ 
ders it clear that it is a matter of great difficulty to transmit variola 
from man to the heifer; that where this rare result is obtained the 
lymph derived from the lesions on the udder or the belly of the animal 
is liable to produce variola when retransmitted to man; and that spon¬ 
taneous cow-pox alone seems to furnish a lymph which is safely inocu- 
lable in generations to the human race. 

Of greater importance is to note here that, either by arm-to-arm vac¬ 
cination, as was formerly extensively practised, or by the use of the 
animal virus which has of late been well-nigh exclusively employed in 
America, there has been conferred upon millions of human beings a 
degree of protection against variola the value of which is beyond esti¬ 
mate. In both methods the lymph is originally derived from the 
female of the bovine race, preferably during the puerperal state, and 
its sources are the vesicular lesions of vacciuia spontaneously arising or 
artificially cultivated about the teats, udder, and adjacent parts. The 
introduction of this lymph into the skin of the human subject is termed 
“ vaccination. ” 

The simple operation of vaccination is performed in many ways, but 
that which especially commends itself to the prudent man is the method 
which eliminates to the largest extent the possibility of transmitting 
any other contagious disease than the one intended. With this object 
in view, no better instrument can be devised than a clean needle, one 
which has been properly disinfected and not previously employed for 
any purpose. The skin of the part selected for vaccination being first 
cleansed antiseptically, and subjected to slight tension by the left hand, 
the vaccinator should scratch or scrape off the epidermis with the 
needle, held in the right hand, by a series of parallel and crossed strokes, 
so as to make three or four superficial erosions, three inches or more 
apart. Each of these multiplex wounds should have the size of the 
nail of the little finger, and should in no case bleed, but merely ooze 
with serum slightly tinged with blood. At such points the lymph is 
to be slowly and thoroughly rubbed in, whether it be supplied in a diy 
form upon ivory points which have been dipped in the serum oozing 
from vaccine-lesions upon the heifer, or be a fluid obtained by crushing 


152 


DISEASES OF THE SKIN. 


and dissolving in water the crust taken from the similar lesion on the 
arm of a child previously unprotected and recently vaccinated. In 
public charities, where, for the most part, this procedure is practicable, 
it is usually sufficient to dip a needle into the lymph flowing from the 
arm of the vaccinifer and to plunge it, thus charged, once or twice 
into the part selected for the operation. 

Between the third and the fourth day after a successful vaccination 
of the unprotected a light reddish, pin-head-sized papule rises at each 
inoculated point. Between the fifth and the sixth day it becomes 
transformed into a translucent, well-distended, occasionally umbilicated 
vesicle, which, when single, may attain the size of that of a finger¬ 
nail. Springing from the multiplex abrasions described above, a minute 
papule usually forms at each point of intersection of the crossed lines 
produced by the scratching with the needle, and the subsequent vesicles 
coalesce, thus forming a compound lesion of rather peculiar aspect. 
It appears often as a small coin-sized plaque, elevated to the extent of 
a line or more beyond the general level of the skin-surface, with a rim 
formed of numerous discrete or confluent vesicles, which in either case 
are closely set together. The compound plaque seems to develop after¬ 
ward as a single lesion, its centre being depressed. After the ninth 
day the fluid becomes opalescent, and desiccates in a reddish-brown 
crust, which, examined in section by a good light after it is com¬ 
pletely dried, exhibits a smooth, homogeneous, shining appearance, with 
a color having the shade of amber. 

Fully as important as any of the metamorphoses of this lesion is 
its rosy-red areola, in the absence of which some authorities contend 
that there is not proper protection. The areola completely encircles 
the compound vesicle in the form of a halo having a diameter of sev¬ 
eral inches, the tissue it invades being often slightly tumid. When 
the pathological process in the focus of this areola is intensified, either 
as the result of the irritant character of the virus, or from extrinsic 
causes (undue exertion of the vaccinated part), the areola may spread 
extensively down the arm, or over the thigh or leg, and eventually 
cover a dense, brawny, and deeply reddened integument. Dermatitis, 
erysipelas, lymphangitis, adenopathy, and severe grades of inflamma¬ 
tion of the subcutaneous tissues may for similar reasons complicate 
the process, which may terminate by central sloughing, ulceration, 
slow repair, and the production of an atypical cicatrix. Ordinarily, 
the subjective phenomena are limited to a mild or annoying itching of 
the vaccinated surface; in other cases, severe burning pain, a feeling 
of tension, and even sympathetic fever may be aroused. 

The acme of a successful vaccination is usually attained between the 
tenth and the fourteenth day, after which the symptoms of the disorder 
gradually subside, the crust falling, if undisturbed, in the course of 
the ensuing week. When “ animal ” virus is employed the duration 
of each of these stages of the disease is usually somewhat prolonged. 

The cicatrix, at first slightly reddened or pigmented, gradually 
assumes the dead-white appearance of scars in general. When typical, 
it is slightly depressed, circular, not irregular, nor deformed by ridges, 
cords, or bands, and “ foveolated, ” exhibiting a series of peripheral 


INF LAMM A TIONS. 


153 


pits or depressions, each of which represents the site of a former minute 
vesicle of simple type. There is strong reason to believe, in the face 
of authoritative statements to the contrary, that the degree of protec¬ 
tion is based in part upon the multiplicity of typical cicatrices, and, in 
view of the rarity of variolous patients with four such traces of suc¬ 
cessful vaccination upon the person, many are prejudiced in favor of 
the English method of producing multiple scars. 

The complications of vaccination are due : first, to the character 
of the virus employed; second, to the character of the soil in which 
it is implanted; and, third, to the external accidents to which the vac¬ 
cine-lesion is subjected. Respecting the first of these sources, there 
are few contagious diseases which may be transmitted by vaccination, 
beside syphilis. When this accident occurs it may be due either to 
the fact of syphilis in the vaccinifer, or to the use of instruments soiled 
with infectious secretions. It is both asserted and denied that the 
lymph from a typical vaccine-vesicle in a syphilitic vaccinifer will neces¬ 
sarily transmit syphilis, if accidentally it be commingled with either 
blood or the products of inflammation at the base of the pock. The 
demonstration of any such fact requires a mass of evidence exceedingly 
difficult to collect, inasmuch as the stage and intensity of the disease 
in the vaccinifer are elements which cannot be ignored in a decision 
of the question. It should be remembered that the vaccine-lesion 
may complete its career during the incubative period of the initial 
sclerosis, the existence of which at the site of vaccination is com¬ 
monly declared later by induration, ulceration, pigmentation, and 
axillary adenopathy. The occurrence of a generalized syphiloderm 
before the chancre of vaccination is completely healed is often the 
first symptom to arouse suspicion. Those further interested in this 
subject should study the cases collected and admirably illustrated by 
Mr. Jonathan Hutchinson, 1 of London. It should be added that the 
popular impression regarding the frequency of this accident is greatly 
erroneous. The rarest of all modes of transmission of syphilis is 
that by vaccination. In all such cases the possibility that the syphilis 
may be hereditary, and its symptoms simply coincident in point of time 
with those of vaccinia, should not be forgotten. 

Exceedingly dangerous is that virus, however good its early char¬ 
acter, in which decomposition or putrefactive changes have occurred 
after exposure, in a liquid form, to the action of heat and the atmos¬ 
phere. Vaccination with lymph thus changed has rapidly been fol¬ 
lowed by fatal results, in consequence of the supervention of pyemia 
or septicemia. 

Complications of vaccinia, due to the character or predisposition of 
the tissues in which the virus is introduced by the vaccinator, are 
usually ascribed by the ignorant or the prejudiced to the causes just 
considered. Post hoe ergo propter hoe is the sole logic of the unin¬ 
formed. In this way almost all other ills of the human family have in 
turn been ascribed to “impurities” and “ humors” introduced by 
vaccination. The language and arguments used in support of these 


1 Illustrations of Clinical Surgery. Phila., 1875. 


154 


DISEASES OF THE SKIN. 


positions have been as exaggerated as they were unreasonable, and have 
borne fruit in the refusal of some physicians of repute to perform 
vaccination and thereafter to assume the responsibility of all the sub¬ 
sequent ailments of the vaccinated. The cutaneous symptoms which 
may thus be awakened are numerous. It will be remembered that the 
contents of the typical vaccine-vesicle are auto-inoculable, and that 
thus the scratching of young patients may produce an abundant crop 
of typical or torn vesicles upon the arms, legs, thighs, hands, and 
fingers. But vaccination may also awaken in the patient, as explained 
above, a latent syphilis, as also a list of cutaneous disorders not con¬ 
tagious in character. Thus, an erythema (roseola vaccinia, vaccinola, 
etc.), eczema in many of its forms, and other exudative processes may 
be first aroused in the integument by the turbulence of a successful 
vaccination. 

These rashes may become generalized, and may even assume a for¬ 
midable appearance. They may appear at any time from the second 
to the fourteenth day after vaccination. A scarlatiniform rash, dif¬ 
fused or in patches, is described by some authors as occurring in this 
way, accompanied by mild fever, and resembling German measles. 
Similarly generalized eruptions, resembling erythema multiforme, 
psoriasis, urticaria, impetigo contagiosa, varicella, and other cutaneous 
disorders, may appear for the first time within the limits named above. 
They usually disappear within a brief time after the vaccine-vesicle 
has completed its involution, and may be followed by slight desqua¬ 
mation or pigmentation. 1 Very rarely vaccinia is followed by purpuric 
symptoms. 

Anomalies of the vaccine-vesicle are occasionally noted, as to shape, 
career, and resulting cicatrix, which are difficult to explain. Thus, 
the papulo-vesicle may not exhibit an umbilicated centre, or may com¬ 
plete its course within unusually short limits; or a harmless ulceration 
may progress beneath its crust, requiring a week, or even more, for 
complete cicatrization. The so-called “ raspberry-sore ” is explained 
by Robinson as resulting from coalescence of small papules, so as to 
form a pigmented tubercle. The scars resulting from many of these 
irregular and non-protective results of vaccination usually in each 
direction form atypical cicatrices, being, in one case, small palm-sized, 
deforming, corded, and representative of large tissue-loss; and, in 
another case, feeble, irregular, and inconspicuous. 

Lastly, the complications of vaccinia due to external accidents of the 
lesion are usually inflammatory in character. The excessive use of 
the vaccinated arm in labor, and of the vaccinated leg in walking, 
standing, and other exertion, may induce, as indicated above, every 
grade of dermatitis, and even ulcerative changes in the site of the 
inoculation, as a result of the intensity of the process. For these 
accidents rest is essential, with the free use of a dusting-powder over 
the inflamed surface. In exaggerated cases lotions of lead-water and 
opium may be employed. These conditions are usually relieved 


1 An interesting paper on vaccinal eruptions was read by Dr. Gustav Behrend, before the 
Dermatological Section of the International Medical Congress, in London, August 5 1881 (See a 
translation of his paper by Dr. Alexander, Arch, of Derm., 1881, No. 4, vol. vii. p. 383.) 


INF LAMM A TIONS. 


155 


without difficulty as soon as the part is put to rest. The atypical scar 
which results seems to be in such cases as protective as others, if only 
the accident have occurred to a typically progressing lesion with dis¬ 
tinctly perfect areola. Vaccine-cicatrices are to be distinguished in 
anomalous situations from maculae atrophicse, the scars of syphilis, 
and other scar-leaving disorders. 

Micrococci have been recognized by Cohn in vaccine-lymph. These 
have been named “ micrococci vaccime,” but their relation to similar 
organisms discovered in the blood and tissues of variolous patients has 
not yet been determined. Wolff 1 claims to have cultivated these 
organisms through fifteen generations. Strauss demonstrated their 
existence in the vaccinal pustules of the calf. 2 

Lipp, of Gratz, reported to the International Medical Congress, in 
London, that he had recognized great similarity, if not identity, between 
the micrococci of vaccinia and those of variola, that he had cultivated 
to the second generation, but had then been unsucessful in producing 
inoculation-effects. These orgauisms were always arranged in groups 
of four, or multiples of four. 


Erythema. 

(Gt. epWr/fia , redness.) 

(Rose Rash. Fr ., Erytheme; Ger., Hautrothe.) 

Redness of the skin, varying greatly in its intensity, duration, and 
distribution, is seen in many different conditions and diseases of the 
integument and of the general economy. In the so-called u idiopathic 
erythemas” the redness may be the sole symptom recognizable, but it 
is usually produced by some definite internal or external form of irri¬ 
tation, or is symptomatic of systemic disease. Erythema may simply 
be hypersemic and be due to a congestion, active or passive, of the 
cutaneous blood-vessels, or the process may go on to exudation and 
inflammation. From a pathological point of view it is evident that no 
sharp line can be drawn between erythema hyperemicum and erythema 
exudativum, yet for clinical purposes it is convenient to make this 
distinction. 

Erythema Hyperemicum (sen Simplex). Erythema simplex is 
a coloration of the skin in various shades of redness, temporarily disap¬ 
pearing under pressure, the lesions differing in size and shape accord¬ 
ing to the extent and degree of the hyperemia by which they are 
induced. 

Simple erythema is seen in the phenomenon known as blushing. 
Ordinarily this is a purely physiological and transitory hyperemia due 
to emotional causes. Cases occur in which the hyperemia thus induced 
persists for hours, together with palpitation and other evidences of cir¬ 
culatory disturbance. Here the erythema is symptomatic of either 


1 Berl. klin. Wochenschr., January 22,1883. 


2 See Magnan, loc. cit. 


156 


DISEASES OF THE SKIN. 


physical or mental disorder. With the former may be classed those 
disorders in which portions of the face remain flushed after eating, 
exercising, exposure to heat, etc. 

Idiopathic erythema, strictly speaking, does not exist; but the term 
is often applied to simple forms of erythema for which no cause is 
recognized. In the great majority of cases a careful search will disclose 
the disease or condition of which the erythema is but a symptom. The 
cause may be found in external irritation too slight and too transient 
to produce a dermatitis, in slight disturbances of the alimentary canal, 
in the nervous irritability of children due to u teething,” in a drug- 
idiosyncrasy, or in one of many other slight disturbances of the general 
economy. Again, the erythema may be a more or less important diag¬ 
nostic symptom of graver constitutional disease, as in the exanthemata, 
typhoid fever, etc. The color in erythema may vary in shade from a 
delicate pink or rosy shade to a dark reddish hue; it may be transitory 
or persistent, and may be limited to circumscribed points, or macules, 
or be displayed in diffuse, ill-defined areas. The character, duration, 
and distribution of these rashes, when due to simple causes, often de¬ 
pend largely upon the peculiarity of the individual. The same source 
of disturbance or irritation may produce different effects on the skins 
of different persons. 

The diagnosis of simple erythema is not difficult, since without 
exudation there is an absence of all other elementary or secondary 
lesions of the skin. The difficult point in diagnosis is to establish the 
cause. 

The treatment of most of the erythemas depends entirely on the 
underlying cause. For the condition of the skin little if any treatment 
is necessary. A dusting-powder is often of service, and if there be 
itching or burning, an antipruritic or soothing lotion may be indicated. 
Ointments are rarely required. 

Erythema Traumaticum. Here the redness is the result of fric¬ 
tion, rubbing, pressure, scratching, or similar external contacts. It 
is observed, for example, in the part pressed by the pad of a truss; in 
the colored circle left about the leg where a tight garter has been worn; 
on the sides of the nose where pressure is exerted by a newly applied 
pair of eye-glasses. These traumatic hyperemias are readily converted 
into exudative affections, if the traumatism be long continued. Inter¬ 
mittent pressure upon the skin permits restoration of the vascular 
equilibrium, and the integument responds to the demand made upon it, 
by increasing in thickness; continued pressure, on the contrary, admits 
of no such restoration, aud the tissue finally becomes thinner, and 
yields before the agent inflicting the injury. Inflammation resulting 
in ulceration may finally supervene. 

Erythema Caloricum. Solar heat in excess and extremes of cold, 
very hot and very cold water, and other heat-conducting substances, 
are also sufficient to induce transitory redness of the skin-surface. In 
the erythema induced especially by solar heat there is frequently an 
increase in the pigmentation of the surface, as in the production of 


INFLAMMA TIONS. 


157 


freckles and “ tan” in persons whose skins are reddened by the sun. 
The darker, brownish, and chocolate-colored stains of the hands and 
face are thus induced. 

Erythema caloricum (Erythema ab igne) may occur in annular and 
odd-looking gyrate patches on the anterior surfaces of the legs in cooks, 
firemen, and stokers, and in persons exposing that portion of the body 
to the direct action of heat. The annular patches may be several 
centimetres in diameter, and vary in shade from a light to deep-red or 
even a purplish tint, deep, often permanent, pigmentation resulting as 
the erythema subsides. 

Erythema Venenatum. A number of chemical substances, dyes, 
and vegetable poisons are capable of producing transient hyperemia of 
the skin. Among these may be mentioned cantharides, capsicum, 
mustard, aniline, chloroform, ether, arnica, and several of the essential 
oils. 

Erythema Gangrenosum. Under this title several singular 
affections of the skin have been described, in which erythematous 
patches appeared and were followed by greater or less extensive destruc¬ 
tion of one or more of the several layers of the skin. T. C. Fox, in 
a description of the appearances in two cases of the affection under his 
observation, concludes that these patches are the symptoms of a feigned 
disease, or of one produced artificially for the purpose of exciting sym¬ 
pathy, etc. The majority of these cases are more properly described 
with dermatitis gangrenosa. 

Erythema Leve is an obsolete term once employed to designate the 
shining redness of the skin in oedema of the lower extremities following 
any disorder sufficient to induce this local tumefaction. 

Erythema Paratrimma is a term once employed for the form 
of deep and lurid redness preceding the formation of a bedsore, an 
accident which in the modern methods of nursing is as obsolete as the 
name once given it. 

Erythema Fugax is a term applied to a transitory redness of 
the skin, usually occurring in small areas, which appears and dis¬ 
appears very much as do the lesions of urticaria; in fact, it may well 
be considered a mild form of urticaria in which typical wheals are 
absent. 

Erythema Pernio (Pernio, “ Chilblains ”) is a form of 
erythema occurring in persons having a feeble circulation or strumous 
diathesis, usually in the young and the very old. The redness is most 
conspicuous, as a rule, on the hands and the feet, merely because of 
the distance of these organs from the centres of circulation. The 
redness is of either a light or dusky shade; is accompanied by tender¬ 
ness, itching, and burning sensations, especially when the part is brought 
near an artificial source of heat; and may be the origin of exudative 


158 


DISEASES OF THE SKIN. 


and other affections of the skin, though the ulceration and sloughing 
which occur in extreme cases are really the results of freezing the 
organs rather than of simple exposure to cold when the circulation is 
impaired. 

The diagnosis in most of these varieties of hyperemia is readily 
made when it is observed that the redness disappears on pressure 
and also that the parts are actually cool rather than hot, the cool¬ 
ness being appreciable by the touch. Not rarely they are both cool 
and moistened with sweat. Pernio may closely resemble an early stage 
of lupus erythematosus, but the latter does not vary with the seasons 
as does pernio, which usually disappears in summer and reappears in 
winter. 

The two conditions are at times related, as individuals are seen with 
pernio of the hands or the feet, and lupus erythematosus of the face. 
Cases are recorded in which the site of a recurring pernio has become 
the seat of a typical lupus erythematosus. 

The treatment of pernio should be directed to the improvement of 
the circulation and the general health. Warm clothing to protect the 
affected parts together with active exercise may do much to prevent 
the recurrence of the disease. Fowler’s solution is considered a pro¬ 
phylactic if given in small doses with the beginning of cold weather. 
The local treatment is by brisk friction and stimulating lotions, such 
as camphorated soap-liniment; acetous, spirituous, and vinous lotions; 
or the use of the ordinary u bay rum” of the shops. Afterward the 
parts should be well dusted with boric acid, and bandaged or wrapped 
in cotton. The severer forms of the disease are considered under 
Dermatitis Calorica. 

Erythema Intertrigo is a hyperemic condition of those cuta¬ 
neous and muco-cutaneous surfaces which are in constant apposition, 
and between which there is a hypersecretion or retention of sweat. 

Symptoms. The erythema is limited to portions of the integument 
which lie in contact with each other and is subject to certain modifica¬ 
tions. The sites of such contact in the human body are the axillae, 
the groins, the cleft between the nates, the inter-mammary and infra¬ 
mammary spaces in women, the superior and inner faces of the thighs, 
the scroto-femoral and the labio-femoral clefts in the sexes respec¬ 
tively, the flexures of the joints, and, in especially fat individuals, all 
those parts where the integument is thrown into fleshy folds, as about 
the neck of infants, and even over the crest of the ilia in fat women. 
In these localities the disorder, beginning as an erythema traumaticum, 
proceeds by its irritative effects to stimulate the secretion of sweat, 
which is freely poured out between the adjacent folds of the skin, and 
may there temporarily be imprisoned. The surface, heated and red¬ 
dened, is also somewhat macerated by the effused perspiration, and 
the latter, when chemically altered, as it is frequently under these 
circumstances, adds still further to the original disorder. The ground 
is thus well prepared for an exudative process, but the disorder may 
be limited to mere hyperemia with hyperidrosis, and disappear before 
the supervention of actual inflammation. 


INF LAMM A TIONS. 


159 


The sensations produced are those of heat and tenderness. When 
the parts in contact are separated the surfaces are seen to be reddened 
and chafed. Here and there very superficial abrasions of the macerated 
epidermis become evident. One such abrasion is always especially 
significant. It is the linear and superficial excoriation which marks 
the line of deepest contact of the two apposed surfaces of the skin at 
the bottom of the angle formed by the two. An offensive odor usually 
proceeds from the part in consequence of the secreted fluid. The secre¬ 
tions of an intertrigo stain, but do not stiffen the linen of the patient, 
and they thus differ from the serous fluid poured out in an exudative 
dermatitis. 

Etiology. The disease is chiefly induced by heat, friction, and moist¬ 
ure—these causes occasionally co-operating. The heat may merely 
be that of the natural temperature of the body, or it may be increased 
by that due to season and climate. The friction also may merely be 
that originating between the surfaces in apposition, or it may be 
increased by clothing or other articles worn next the skin. The 
moisture which produces maceration of the epidermis is that origin¬ 
ating in the perspiratory follicles, their secretion being doubtless 
stimulated by the heat and friction. The interchange of operation 
of these three factors, lastly, is shown by the fact that friction, if 
severe, is capable of increasing the temperature of the part to which 
it is applied. 

As aggravating causes may be named other physiological secre¬ 
tions and excretions, retained in contact with the surfaces affected 
with an intertrigo. Thus, the feces of the infant left in contact 
with its nates upon the napkin; the urine of the old man with pa¬ 
ralysis of the bladder or with “overflow” from prostatic disease; the 
milk of nursing-women dribbling over the breast to the infra-mam¬ 
mary region; retained lochial, menstrual, and similar discharges, are 
all efficient in this regard, and are particularly apt to induce that 
form of dermatitis to which the intertrigo then plays a subordinate 
part. Fleshy and gouty persons furnish the most fertile field for these 
accidents. 

Diagnosis. The recognition of a simple erythema intertrigo is a 
matter of no difficulty, if regard be had to the exciting and aggravat¬ 
ing causes enumerated above, and to the special localities where such 
hyperemia generally originates. If an eczema or a dermatitis super¬ 
vene, the fact will appear from increased subjective sensation (usually 
a severe itching), from an infiltration of the affected integument, and 
from the appearance of those lesions and discharges which are signifi¬ 
cant of these forms of inflammation of the skin. It must be remem¬ 
bered that a transition from a simple erythema to a dermatitis of these 
regions is of frequent occurrence. Erythema intertrigo may occur as 
a mild form of dermatitis seborrhoicum. 

The special sites of preference of intertrigo are those of the disease 
named by Hebra “ eczema marginatum,” or ring-worm as it occurs 
upon the parts of the thighs covered by the “reinforced” patch in 
the trowsers of cavalrymen. The disease is properly named “ tinea 
circinata cruris,” though it is found also about the axillae, the buttocks, 


160 


DISEASES OF THE SKIN. 


and the groins of both sexes. Here the disorder, however, is of the 
exudative type, and, moreover, is distinguished by a characteristic 
*•' festooning ” of the elevated border marking the advancing limit of 
the disease. The microscope, by revealing the existence of a fungus, 
will, of course, put an end to any doubt. In intertrigo the most 
marked evidence of disease is to be recognized in the deeper parts of 
the cleft between the two adjacent skin-surfaces, while in tinea circinata 
cruris the growth of the parasite is most active at the advancing border 
of the patch, which is, moreover, perceptibly elevated above the sound 
skin. 

Treatment. Erythema intertrigo is an exceedingly common affection 
of the skin, and it occasionally proves of great annoyance to those 
suffering from it. The skill of the young practitioner is often tested 
early in his professional career by his management of just such cases; 
and not a little may depend upon the success with which he may be 
rewarded. 

The affected surfaces should gently be cleansed by ablution with soap 
and warm water, and the offensive odor of the secretions remedied by 
the addition to the water of a weak solution of carbolic acid, or of the 
dilute liquor sodse chlorinatse. The parts are then to be carefully 
dried with a freshly laundered towel or a soft handkerchief, and after¬ 
ward one of the dusting-powders very thoroughly applied. To be of 
service, these powders must be quite impalpable, and, if compounded 
by a druggist, be sifted through millers’ fine silk bolting-cloth. The 
articles chiefly used for this purpose are: bismuth, starch, zinc oxid, 
French chalk, lycopodium, or, when an antipruritic effect is designed, 
camphor. Combinations of several of these are at times effective. 
The formula of McCall Anderson is highly esteemed: 


R.—Zinci oxid. pulv., 

Camphorse pulv., 

Amyli pulv., 

Sig.—Anderson’s dusting-powder. 


3ss; 

Ej; 


16 

6 

32 


M. 


The following is the formula for a dusting-powder recommended by 
Klamann : l 


R.—Talc, venet. pulv., ,^v; 20; 

Acid, salicyl., gr.’iij; 2 

Magnes. ust. subtil, pulv., ^jss; 5) M. 

Sig.—Dusting-powder. 

The “ Oswego gloss-starch” and the “ corn-starch farina” sold in 
America are finely bolted, and answer well alone or in combination 
with some of the other articles above named. The chief objection to 
the starch-containing powders is their tendency to form “ cakes” or 
rolls when wetted with sweat, these masses further irritating the tender 
surface of the skin. Such an objection does not apply to lycopodium, 
which not only under the microscope exhibits no salient angles, but 
on account of the oil it contains is not miscible with water . 2 

The affected surfaces of the skin must also be separated in order to 


1 Hebam. Kalend., Obstet. Gazette, March, 1882. 

2 Unna’s salve muslins and pastes will be found effectual and neat applications in many forms 

f int.PTT.rnwY * 



INFLAMMA TIONS. 


161 


prevent further friction. A thin strip of lint, antiseptic cotton, or 
medicated wool may be used for this purpose, and must be pushed 
well up to the deeper portions of the cleft, where the secretion chiefly 
forms. Occasionally it will be found useful to anoint this absorbent 
layer with cold cream or with vaselin. Where an astringent effect 
is desired lycopodium or other dusting-powder may be compounded 
with tannin, alum, or similar substances. The list of lotions may at 
times be also consulted with advantage. Thus, cologne-water, weak 
spirit-lotions, tannin, or aromatic wine, or the carbonate of magnesium, 
may each be serviceable. Lastly, carron oil (equal parts of lime-water 
and linseed-oil), spread thickly upon linen, will possibly give more 
relief than other articles named, the chief objection to it being the 
consequent soiling of the patient’s clothing. 

Symptomatic Erythema. This may be of either active or passive 
form. A long list of physiological and pathological causes operating 
upon the system at large are capable of inducing active symptomatic 
hyperemia of the skin. This condition may be generally diffused, or 
occur in surface mottlings and markings of various sizes and shapes. 
Thus, the skin of the face may intensely be reddened in a paroxysm 
of rage; and that of the limbs of a teething child be covered with rosy 
maculations in consequence of the reflection to the surface, through the 
medium of the nervous system, of the irritation induced by eruption 
of a tooth. In consequence of the rosy tint assumed by several of these 
rashes they have long been termed “ roseola,” a name which to-day is 
held to describe a symptom rather than a disease. The word “ roseola ” 
is still associated in the minds of many with the earliest syphiloderm, 
but that eruption is now designated by the best authors as the erythe¬ 
matous, or macular, syphilide. 

Roseola infantilis is described by some authors as a distinct affection 
in which there is some fever and other constitutional disturbances last¬ 
ing a few hours or even a few days. The exanthem varies greatly in 
extent and distribution. It is usually macular or punctate, but may 
be finely papular; it is most common on the trunk, but may appear on 
other parts of the body; it may closely simulate scarlatina or measles. 
It is probable that these phenomena are always the manifestations of 
some systemic or local disorder and not, as the name would indicate, due 
to an indefinite disease. 

Several of the severer constitutional maladies betray their morbid 
influence upon the central nervous system by a speedy efflorescence of 
this character. A lurid erythema of the axillary or the inguinal region 
may precede by several days the eruption of confluent variola. Cholera, 
cerebro-spinal meningitis, diphtheria, enteric and other fevers are thus 
at times accompanied, preceded, or followed by rashes. A study of 
these rashes, is of the utmost importance to the diagnostician. Children 
who are really susceptible to the disease are often supposed to possess 
an immunity from scarlatina, as the symptomatic erythema previously 
displayed was misconstrued. Vaccination may be followed in from 
one to eight or nine days by a macular or more diffuse erythema of the 
trunk and extremities, usually accompanied by some febrile reaction. 

11 


162 


DISEASES OF THE SKIN. 


Symptomatic passive erythema is usually characterized by a cyanotic, 
purplish, or darker hue of the integument, resulting largely from accu¬ 
mulation in excess of carbonic acid in the blood. The temperature of 
such skins is either normal or below the normal standard, as in those 
cases where gangrene ensues. A long list of conditions may be named 
in which these symptoms may be noted, including derangement of the 
blood-vessels from imperfect innervation, direct pressure, or disease of 
the heart or vascular walls. 

These erythemas may be either circumscribed in area or general. 
The term ‘ ‘ livedo ? ’ is applied to circumscribed regions of passive 
erythema. Sometimes the nose, cheeks, fingers, or toes exhibit this 
form of disease. The so-called u symmetrical gangrene ” of the fingers 
belongs to the same category. Cardiac cyanosis, or morbus ceruleus, 
is a name given to a generalized dark blue discoloration of the entire 
surface, due to continued patency of the foramen ovale. 

Erythema Scarlatiniforme (Scarlatinoid Erythema, Desquama¬ 
tive Scarlatiniform Erythema, Scarlatinoide, Erythema Punctatum, 
Roseola Scarlatiniforme, “ Scarlet Rash,” Erytheme Infectueux). 
Erythema scarlatiniforme is a name given to an eruption arising from 
a large number of causes and varying considerably in character, but 
having a tendency to simulate the rash of scarlatina. This condition 
has been described as an idiopathic disease, but it has so often been 
demonstrated to be a symptom only of other disorders that its existence 
as an independent disease may well be doubted. 

Besnier, Brocq, and other French authors describe an erytheme scar- 
latino'ide , which is acute in type and which is always secondary to other 
infectious diseases, to auto-toxemia, or to medicinal or food toxemia; 
and an erytheme scarlatiniforme desquamatif which is subacute in type, 
and which may be idiopathic, secondary to other infectious diseases, or 
be artificially produced by drugs. While it is often clinically con¬ 
venient to make a distinction between acute and subacute forms of 
scarlatiniform erythema, there are no good pathological or etiological 
grounds for makiug such distinctions, since a given drug or given form 
of intoxication may produce the acute type in one individual and the 
chronic form in another. 

Symptoms. In the acute type, which is the more common of the 
two forms, the rash may be preceded by a day or two of fever and 
other evidences of constitutional disturbance, or it may appear sud¬ 
denly without premonitory symptoms. The exanthem spreads rapidly 
and in a few hours, or at most in two or three days, reaches its full 
development. The rash may be punctiform, macular, or diffuse, and 
the color may be any of the shades of red, but it is usually a bright 
scarlet. In some instances it has all the appearances of a typical scar¬ 
latinal rash, except that it may begin on any part of the body, often 
sparing the face, and that desquamation begins much earlier than in 
scarlatina. There is usually some fever, malaise, and other constitu¬ 
tional disturbance that may vary greatly in intensity, depending upon 
the disease of which the exanthem is a symptom. The mucous mem¬ 
brane of the mouth, the tongue, and the fauces may be reddened or 
be denuded of epithelium, but the characteristic strawberry-tongue of 


INFLAMMA TIONS. 


163 


scarlatina is wanting. The nails and the hair may be shed, but only 
in exceptional cases. 

Desquamation usually begins in from two to six days, sometimes 
before the disappearance of the rash, and it may even occur on surfaces 
which had not perceptibly been reddened. The scales are usually 
furfuraceous,. but they may be large and abundant; in rare instances 
the entire epidermis of the hand may be shed in glove-like form. 

The subacute forms of scarlatiniform erythema differ from those 
described above in that constitutional disturbances are less, the rash 
has a greater tendency to be diffuse, and, together with the desquama¬ 
tion, may persist for weeks or for months, recurrences being frequent. 
Occasionally cases are found in which recurrences are so frequent as to 
make the condition practically continuous and clinically indistinguish¬ 
able from the milder forms of dermatitis exfoliativa. 

Etiology. Idiosyncrasy is a most important factor in the etiology 
of these forms of erythema, which appear in certain predisposed indi¬ 
viduals as a result of causes totally insufficient to produce the same 
phenomena in most persons. The exciting causes are numerous. 
Among those reported are : infectious diseases, septicemic conditions, 
toxemias of varied origins, peritonitis, rheumatism, ague in children, 
gonorrhea, abscess, empyema, uremia, tuberculin-injections, sewer- 
gas poisoning (Crocker), certain articles of food, and many drugs. 
The causes are sometimes external, as in mercurial inunctions, exposure 
to high temperature, etc. 

Diagnosis. It is most important to distinguish this rash from that 
of scarlet fever. Commonly the diagnosis is not difficult, as in erythema 
scarlatiniforme the constitutional symptoms are slight; the rash appears 
rapidly, beginning on any part of the body; desquamation begins 
early; the fauces though red are not swollen; and there is absence of 
the strawberry-tongue. Occasionally the rash may closely resemble 
that of measles or rotheln, but the history of the case and the absence 
of other symptoms peculiar to these affections should make the diag¬ 
nosis clear. As a rule, an examination of the rash alone is insufficient, 
and a diagnosis of erythema scarlatiniforme should not be made until 
the other exanthemata have been considered and excluded. 

Treatment. This depends entirely on the underlying cause or con¬ 
dition. The rash itself rarely calls for any treatment. If there be 
itching or burning sensations, a simple dusting-powder, with or without 
an anti-pruritic or a soothing lotion, may be used to make the patient 
more comfortable. 

Erythema Multiforme. 

(Erythema Exsudatiyum Multiforme. Fr., Erytheme 
Papulo-tuberculeux.) 

Statistical frequency in America, 1.021. 

Erythema multiforme is an exudative skin disease, in which appear flat or elevated 
lesions of an erythematous type in various forms, the exanthem being at times 
symptomatic of constitutional derangement. 

Symptoms. In this affection, which is usually of symmetrical devel¬ 
opment, erythematous maculae, flattened papulae, and even large flat 


164 


DISEASES OF THE SKIN. 


nodosities, very rarely vesicles, occur, usually upon portions of the 
extremities, the forearms, the legs, and the dorsum of the hands and 
feet. From the beginning the lesions are more or less elevated and 
oedematous. The eruption, which is generally recognized in clearly 
defined patches, usually begins with pin-head- to finger-nail-sized mac¬ 
ules of a darkish-red shade that lose their color under the pressure of 
the finger, and in the course of some hours exhibit tumefaction in 
various degrees, thus producing the papules, tubercles, and nodes 
already described. The disease may persist for but a few days, but 
in severer grades it lasts for several weeks. In the height of the 
exudative process there is usually an efflux of the coloring-matter of 
the blood into the skin which is the site of the several lesions, and 
thus are produced the singular shades of reddish-black, purple and 
red, blue and red, yellow and orange, that are characteristic of simple 
bruises of the extremities when the injury has been sufficient to cause 
extravasation of blood. The lesions occur in various shapes, sizes, and 
shades, a number of names having been used to designate their several 
appearances, that require explanation though they are without any 
practical value. 

Erythema Annulare (or Circinatum) is characterized by a central 
depression and paling of color, and a peripheral extension of the erythe¬ 
matous patch in the form of a ring. 

Erythema Figuratum occurs in gyrations formed by coalescence 
of two or more annular circles. 

Erythema Induratum is considered with the tuberculous affec¬ 
tions of the skin. 

Erythema Iris (Herpes iris) is the result of successive new erythe¬ 
matous centric lesions, which at times form several differently shaded 
concentric rings. 

This variety of multiform erythema often occurs without other man¬ 
ifestations of the same disease in a patient exhibiting its lesions. It 
is not rarely observed in a single patch on the back of one hand. 
There may be a central vesicle or bulla with a series of concentric 
rings about it, the latter constituted either of discrete or of confluent 
vesicles or bullae. There is always a narrow and purplish shaded 
areola about the fully distended or the flattened and depressed central 
lesion, and the “ iris” effect is produced by the contrast of the whitish 
fluid in the chambers with the color of the pinkish zone. Patches 
may symmetrically develop on both hands or the fingers of the two 
hands, and, finally desiccating, may complete a cycle of three or four 
weeks’ duration. Variations occur by reason of effusion of fluid until 
there form large bullae, which may coalesce or be filled with blood; 
while, according to Crocker, hematuria may result with severe involve¬ 
ment of the mucous membrane of the lips, the tongue, the soft palate, 
and other parts of the mouth, ulceration rapidly ensuing. 

Cases with these complications should really be classified with the 
grave forms of pemphigus, to which they properly belong. 


INF LAMM A TIONS. 


165 


Under tli® title Herpes Iris of Bateman, French authors describe 
the Hydroa Vesiculeux of Bazin. In this affection there first 
appear reddish papules, in the centre of each of which there forms a 
faintly developed vesicle, which desiccates and thus produces a delicate 
crust. New well-distended or abortive vesicular lesions form periph¬ 
erally in successive reddish, bluish, or purplish rings about the central 
crust, with an erythematous zone about the patch. In this disorder, 
also, may succeed generalization of the eruption, involvement of the 
mucous surfaces (including severe oral and labial lesions), and grave 
symptoms of a general character. 

Erythema Marginatum is that form of the disease in which a 
distinctly elevated and defined marginal band is left as the sequel of 
an erythematous patch. 

Erythema Nodosum (Dermatitis Contusiformis; Fr., Eryth^me 
Noueux) is regarded by several authors as a distinct affection, in which 
the characteristic lesions are of the dimensions of semi-globular pea- 
to fist-sized tumors, pale red to livid blue in color, tender upon pressure, 
exhibiting in their involution the variegations of hue already described. 
They occur at times not only in the localities named above, but also 
upon the trunk and the face. Though occasionally becoming so soft 
to the touch that fluctuation may seem to be present, they never 
terminate by suppuration. 

They occur most often in youth, in girls more often than in boys, 
with acute or subacute symptoms, frequently with rheumatoid pains 
and febrile temperatures. The oval or roundish, erythematous or 
empurpled nodes, varying in size from that of a small nut to that of 
a pigeon’s egg, are most often seen on the lower limbs, though they 
appear also on the thighs, the buttocks, and the forearms. They are 
usually tender on pressure, and often painful. They may disappear 
in a fortnight, but occasionally observe a stadium of six weeks’ duration, 
forming and disappearing in crops. The petechial appearance of the 
spots where they have existed is that of the characteristic “ black-and- 
blue” mark. By some authors this disease is recorded as associated 
with tuberculosis, an observation probably due to the fact that it appears 
so often among the poorly nourished and ill-housed. It unquestionably 
occurs most frequently in the spring and autumn. Other causes cited 
are: malarial chills, temperature-changes, rheumatism, gout (rare in 
young adults), arthritis, endocarditis, urethral irritation (blennorrhagic, 
instrumental), medicamentous ingesta, alcoholic excesses, and denti¬ 
tion^?). 

Erythema Papulatum (or Papulosum) and Erythema Tuber¬ 
culatum (or Tuberculosum) are those forms in which occur lesions 
respectively of a papular or a tubercular type. 

Erythema Urticatum is that form in which there is severe 
itching and., as a result, scratching of the lesions, with crusts of dark 
dried blood at the summit of each. This crust is surrounded by the 


166 


DISEASES OF THE SKIN. 


light-red or bluish-red, flattened or elevated patch characteristic of 
the disease. 

Erythema Vesiculosum and Erythema Bullosum are rare and 
exceptional forms in which the exudation is sufficient to raise the horny 
layer of the epidermis into larger or smaller serum-containing cham¬ 
bers, which may be, as regards the erythematous patch, of central or 
peripheral situation, and which may crown the summit of papule or 
tubercle. The fluid is usually removed by absorption, and is rarely 
set free by rupture of the vesicle or bleb. 

A number of medicaments, when ingested or externally employed, 
are capable of producing eruptions identical in appearance with the 
lesions of erythema multiforme. For descriptions of these the reader 
is referred to the chapters devoted to Dermatitis Medicamentosa and 
Dermatitis Venenata. Quinin, arsenic, belladonna, chloral, salicylic 
acid, the iodin and bromin compounds, and other substances are often 
responsible for these symptoms. 

The name c< multiforme,” given to this disease by Hebra, is justified 
by the singular diversity of lesions which it displays. These lesions 
are remarkable, not merely for their variety, but also for their occurrence 
in such variety both simultaneously and successively, and for their 
rapid change from one type to another. 

The subjective symptoms, save in the urticarial form of the disease, 
are usually of a trifling character. The slight sense of heat and burn¬ 
ing awakened by the lesions is altogether out of proportion to the 
extent of their development. 

The symptoms, however, indicative of a general disturbance of the 
system, may be of a marked character. General malaise, fever, inap¬ 
petence, pharyngeal inflammation, chills, severe gastro-intestinal dis¬ 
order, rheumatoid involvement of the articulations, and even organic 
changes in the heart (valves, endocardium, and pericardium), lungs, 
and kidneys (Kaposi) have all been noted as coincident or as causative 
phenomena. In many of these cases it is clear that the exanthem 
belongs to the list of symptomatic erythemata, and that it is of insig¬ 
nificance in comparison with the grave general condition. It may thus 
be the precursor of typhoid fever, malaria, severe articular rheumatism, 
or may become even an abortive expression of these disorders. With 
these exceptions, however, the prognosis is in general quite favorable, 
as the disease may terminate in a few days, and rarely exceeds a month 
in duration. 

Occasionally the mucous membranes are affected to a disagreeable or 
even painful extent. Thus a sudden tumefaction of the uvula may 
supervene upon the cutaneous symptoms, even in cases sufficient to 
impede respiration; or the lining membrane of the larynx may be 
involved, and the resulting aphonia in various degrees persist for two 
or three days. 

Etiology. The affection is commonest in the spring and autumn; it 
occurs in the young or in the early periods of adult life; the papular 


INF LAMM A TIONS. 


167 


and tubercular forms are more common in men, and the nodose forms 
in women; in many cases it occurs in those who are affected with rheu¬ 
matism. In a valuable contribution to the visceral complications of 
erythema exudativum multiforme Osier 1 has shown that in many 
patients the cutaneous symptoms are merely surface-expressions of a 
visceral disorder; and indeed that the skin-symptoms may wholly be 
absent when the disease is in progress. In the cases studied by him 
there was the widest range of cutaneous phenomena,from simple purpura 
and urticaria to grave hemorrhages into the skin and subcutaneous 
structures, and angio-neurotic oedema. All of Osier’s cases were re¬ 
markable for their tendency to recurrence; in but few patients was the 
outbreak single. Among the concurrent disorders detailed by him 
are pneumonia, endocarditis, and pericarditis; hematuria, albuminuria, 
and anasarca ; vomiting and severe abdominal pains. The percent¬ 
age of fatalities was 21.3. Mackensie 2 has called attention to the 
relationship of erythema multiforme to rheumatism and to purpura 
rheumatica. There can be but little doubt that its etiology includes 
a list of varying and widely differing causes. Severe manifestations 
of the disease have been observed in a young woman with extensive 
ulceration of the cervix uteri. Tilbury Fox noted a frequency of 
symptoms in young servants brought to town from the country. It 
is not rare in young female immigrants who have recently made a 
u steerage” passage to America. 

Pathology. Erythema multiforme is essentially an hyperemia of 
the integument that, under certain obscure influences, advances more 
or less rapidly to the stage of mild grade of inflammation with con¬ 
sequent exudation. If, with Landois and Lewin, it be accepted that 
the process is the result of vaso-motor nerve influence, it cannot be 
determined whether these nerves are irritated at points of origin or of 
distribution. In the case of erythema nodosum Hebra advances the 
hypothesis that the morbid process is essentially an inflammation of 
the lymphatic vessels. In some cases it is evident that there is extrav¬ 
asation of blood from the vessels into the skin of the affected part. 

Leloir 3 discovered in the papules, tubercles, and bullae of the erythe- 
mata only the phenomena of hyperemia and exudation limited to the 
corium and subcutaneous tissue; and Villemin 4 simply confirms these 
facts. 

Crocker, examining a patch of erythema tuberculatum, recognized 
merely a cell-effusion in the upper portion of the corium extending 
sparsely below, and then chiefly along the ducts and follicles. There 
was slight rete proliferation. 

Diagnosis. Erythema multiforme is always to be carefully distin¬ 
guished from the traumatism producing bruises, especially upon the 
lower extremities. This point may have an interesting bearing upon 
certain medico-legal questions, especially in the case of young children. 5 


1 American Journal of the Medical Sciences, December, 1895. 

2 British Journal of Dermatology, April, 1896. 

3 Bull, de la Soc. Anat., 1884, p. 294. 4 Gaz. Hebdom., 1886, Nos. 22, 23. 

5 Since this paragraph was written the author, in conjunction with a number of other physi¬ 

cians, was summoned as a witness in a case where both parents of a lad who exhibited the lesions 
of polymorphous ervthema, and who died suddenly, were charged with beating their child to 
death. They were exonerated on the basis of the evidence of the experts. 


168 


DISEASES OF THE SKIN. 


The tendency of the disease here considered to symmetrical arrange¬ 
ment upon the two sides of the body, the occurrence of lesions evi¬ 
dently dating from several periods, in which successive crops appear, 
and the absence of all history of external injury, will usually suffice 
to establish a diagnosis. Among the precocious affections of the sub¬ 
cutaneous connective tissue in syphilis Mauriac described a lesion 
resembling somewhat the symptoms of erythema nodosum; but in such 
cases, and especially in women, mucous patches of the vulva, the anus, 
or the mouth, with coincident adenopathy, would point to the real 
nature of the disease. Syphilitic nodes and gummata are distinguished 
from the lesions of the nodose forms of erythema by the pain attending 
the former, their fewness, their overlying integument untinted save 
when actually softening and near the point of disintegration, their obvi¬ 
ously subcutaneous site,and the usual concomitant symptoms of late lues. 

The chief points by which a diagnosis of the erythemata in general is 
established are: the recognition of the vivid coloring of most of the 
lesions; their oedematous character; the pigmentation following those 
situated on the lower limbs; their association with rheumatism or 
rheumatoid pains; their febrile phenomena; their symmetry as a rule; 
and the accompanying malaise. The wheals of urticaria are smaller, 
more whitish centrally, more closely packed together, less symmetrical, 
rarely grouped, and, as a rule, decidedly more acute than those of 
erythema. Cases difficult to assign to either disease are common, and 
an error in either direction is not serious. Rubella (German measles) 
is to be distinguished by its adenopathy, its pharyngeal symptoms, and 
its flattish spots. In eczema erythematosum there is less definition of 
each patch, and the redness is commonly diffuse; papular forms of 
eczema are usually commingled with other readily distinguished symp¬ 
toms of that disease. 

The iodid of potassium and a few other drugs administered inter¬ 
nally are capable of producing almost every one of the lesions described 
above. In the erythemata for which iodin and bromin salts have 
been administered, with the production of skin-symptoms, the confusion 
produced becomes a fruitful source of error. 

Treatment. As the disease under consideration progresses naturally 
to a favorable termination within the course of a few weeks, the duty 
of the physician is usually limited merely to the question of diagnosis. 
He should remember that the larger lesions seen in erythema nodosum 
never suppurate, and thus not be tempted to open them with a lancet. 
Local treatment is rarely called for, and in any case should be restricted 
to the application of hot or cold water, as found most grateful to the 
patient, with possibly the use of a weak lead-lotion. Internally such 
medication should be employed as is indicated by the general condition of 
the patient. Iron, quinin, strychnin, and dilute hydrochloric acid will 
be found beneficial in many cases. Constipation and indigestion are to 
be corrected by appropriate measures. When the disorder is evidently 
purely symptomatic the internal treatment is to be directed to the gen¬ 
eral condition present. In rheumatic cases the indications for such 
treatment are clear. When the erythema produces extensive oedema of 
the uvula incisions may be requisite to prevent dyspnea and dysphagia. 


INFLAMMA TIONS. 


169 


Prognosis. It will be gathered from what has preceded that the 
prognosis is always favorable. The fatal cases reported are usually 
those where the result was due to grave constitutional conditions, and 
where the erythema multiforme was an insignificant feature of the 
malady. The disease.may relapse in susceptible individuals at those 
periods of the year when it is most frequently observed. 


Urticaria. 

(Lat. urtica, the nettle.) 

(Hives, Nettle-rash. Fr., Urtica ire; Ger., Nesselsuch, 
Nesselfieber.) 

Statistical frequency in America, 2.47. 

Urticaria is an exudative affection of the skin in which appear ephemeral, whitish, 
or rosy-tinted wheals surrounded by a reddish areola, giving rise to an intense 
pruritus. 

Symptoms. This disorder may be ushered in by constitutional symp¬ 
toms, such as inappetence, malaise, cephalalgia, or mild pyrexic 
symptoms lasting for a few hours or even for a day or more. 

With, and often without, such prodromic symptoms the eruption 
suddenly appears in the form of wheals upon the skin-surface, that 
frequently disappear with equal rapidity, leaving behind no traces of 

Fig. 40. 



Aufographism in urticaria. (From a photograph.) 


their existence save a slight and transitory hyperemia of the affected 
spot. The lesions may be as small as the size of a finger-nail or that 
of a coffee-bean, and usually are of this size; but in certain rare 
instances “ giant wheals 99 are seen, large tomato-sized projections or 
flat elevations of broad areas of the integument, that cover the greater 
part of the belly or buttock. In color the lesions are either rosy- 
red or whitish, and are usually surrounded by an hyperemic areola. 
They may be isolated and few, or be numerous and closely packed 
together; they may even coalesce so that individual wheals are scarcely 
recognizable. They are usually firm and semi-solid to the touch. 
Rarely the horny layer of the skin is raised in fluid-containing lesions 
by the sudden effusion of serum beneath. In contour they are roundish 





170 


DISEASES OF THE SKIN. 


or oval-shaped, but a variety of curious outlines may result from the 
irregularity of their development. Concentric circles, lines, bands, and 
even figures are in this way produced. The finger-nail drawn across 
the unaffected portions of the skin of a patient with urticaria will often 
produce a linear wheal of extent corresponding with the line of irrita¬ 
tion. It is said that in this way the so-called “medium” with a 
sensitive skin exhibits written characters upon the surface of his 
body. 

The subjective sensations induced by these lesions are distressing in 
varying degrees, according to the susceptibility of the individual. 
Every grade of pruritic burning, tickling, crawling, pricking, and 
especially stinging sensations are thus engendered. The efforts of the 
patient to secure relief by scratching, not only serve still further to 
develop the eruption, but also to irritate, tear, and otherwise wound 
the lesions already in full evolution. In this way serous effusions 
are produced at the summits of the wheal; and in this way, also, 
lesions really transitory in their course may be changed to more per¬ 
sistent, deeply colored, flat, lenticular papules. Where the skin is 
delicate and thin, as that of the lids and prepuce, considerable oedema 
may result. 

All parts of the body may become affected, irrespective of age and 
sex, though children are particularly liable to the disease. There are 
few very young children with skins unwashed for an entire month, 
who will not exhibit urticarial symptoms if there be an added irritation 
of the surface. 

The lesions numerically may be few or be so numerous as to cover 
the entire surface of the body. Though more frequently acute in 
course, they often recur from apparently insignificant causes, or even 
become chronic. In many cases trivial the disease may become so 
aggravated as to make the largest demands upon the skill of the 
physician. 

The rapidity of appearance and disappearance of the lesions visible 
upon the skin is a characteristic feature of the disease. In some 
instances but a few moments are required after the operation of an 
efficient cause to develop a large number of closely packed wheals. 
Even while they are under inspection it can be noted that there is a 
change in individual lesions, some fading or completely disappearing, 
while others are newly developing. 

A number of names have been employed to designate the several 
external peculiarities of the lesions as they are presented to the eye. 
Thus, Urticaria annularis occurs in rings; U. figurata, in gyrations 
from union of several lesions or patches of lesions; U. vesiculosa and 
U. bullosa, where there is a vesicular or bullous development at the 
summit of the lesion; U. papulosa (or Lichen urticatus), where there 
is a combination of the features of the wheal and the papule, the 
lesions being naturally grape-seed- to coffee-bean-sized, and covered 
with blood-crusts where their apices have been torn in scratching; 
U. tuberosa, where “ giant” wheals occur, some attaining the size 
of a hen’s egg; U. hemorrhagica (Purpura urticata), where the urti¬ 
carial element is developed in a lesion produced by cutaneous hemor- 


INFLAMMA TIONS. 


171 


rhage; and U. evanida, or perstans, where there is, respectively, a 
rapid or a slow process of involution in the characteristic symptoms. 

Urticaria Pigmentosa (Xanthelasmoidea, of Fox). This 
disorder, once regarded as an affection of great rarity, has now 
been observed in a number of cases in almost all the large centres of 
population. The disease is characterized by the occurrence in early 
infancy, sometimes but a few hours or a few weeks after birth, of 
elevated rosy or reddish wheals which are succeeded later by flattish 
or slightly elevated light or dark- 
brownish or buff-colored macules. 

There are three tolerably distinct types 
of the affection: those exhibiting plane 
lesions with equally flattened macula- 
tions; those with tubercular, nodular, 
or variously sized and shaped wheals; 
and mixed varieties, the latter being 
commonest. The mingling of a facti¬ 
tious urticaria with lesions long existing 
and long maculated is not rare. A 
characteristic feature of this form of 
urticaria is the tendency of the wheals 
to recur at the same site, and where 
pigmentation remains new wheals may 
be produced by irritation. Cases may 
be classified into those accompanied by 
itching and those not thus character¬ 
ized; but these differences are due to 
accidental rather than to essential 
causes. The eruption, which at the 
outset may appear as late as the third 
year, commonly displays itself first on 
the neck and shoulders and then rapidly 
spreads to the head and the extremities, 
eventually invading the entire body- 
surface—in well-marked cases even in¬ 
cluding the mucous membranes. The 
lesions are at first of the usual urti¬ 
carial type, each with delicate zone, but 
soon lose their distinct contour and 
elevation, and become flatter and pig¬ 
mented, the color in pronounced cases 
being a distinct yellow, deepening to a decided coffee-and-milk hue. 
After isolated tubercles once acquire the deeper tint they may persist 
for years; may return in crops ; may even at times be commingled 
with bullae which desiccate in crusts; may form plaques of infiltra¬ 
tion ; may be covered at times with an erythematous blush due to 
hyperemia of parts long affected; and, when itching is intense, may 
exhibit the general signs of the scratched skin. In some of the 


Fig. 41. 



Urticaria pigmentosa. (From a 
photograph.) 



172 


DISEASES OF THE SKIN. 


reported cases, after involution, whitish instead of pigmented spots were 
left in a smooth or a wrinkled and scar-like skin. 

Etiology. The cause is unknown. The sexes are nearly equally 
represented among patients. 

Pathology. Sections of tubercles have been made by numerous ob¬ 
servers, including Unna, Raymond, Pick, and Thin. It is clear that 
some effusion occurs in the corium with cell-infiltration and small 
hemorrhages. The disorder is unquestionably an angio-neurosis due 
to special changes of the vaso-motor centres. According to Brocq, the 
predominant elements of the infiltration are the mast-cells. 

Diagnosis. Urticaria pigmentosa is to be distinguished from the 
slight pigmentation left after well-marked urticaria of later years by 
the beginning of the disease in infancy and by the persistent buff- 
colored tubercles. Xanthoma in all its forms is readily distinguished 
by its persistence in special regions, the eyelids, for example; by its 
first appearance in many patients at a later period of life than infancy; 
and by its characteristic chamois-leather-yellow shade. 

Treatment. Xo treatment has hitherto been so successful as to justify 
its recommendation. The best results are obtained after stimulating 
rather than soothing baths, at a later period of life than during the 
first six months. After such stimulation with salt and water and 
alcohol and water a boric-acid dusting-powder is always applied. 

Angioneurotic (Edema (Acute Circumscribed (Edema, Acute 
Idiopathic (Edema, Periodic Swelling, Acute Non-inflammatory 
(Edema, Giant Swelling) is characterized by the appearance on various 
parts of the body, particularly the face, the extremities, and the throat, 
chiefly of male subjects who may have inherited a tendency to this or a 
similar disorder, of suddenly evolved swellings of the skin, usually dull 
red in hue, contrasting vividly with the color of the surrounding integu¬ 
ment, and disappearing in the course of a few hours. These swellings 
are commonly the seat of disagreeable sensations of fulness, burning, 
throbbing, or scalding; and if the swelling chance to obstruct a mucous 
tract (nasal, pharyngeal, laryngeal, etc.), there are symptoms of a 
distressing character, due to the transitory occlusion. The tumefactions 
are so large as to involve an entire organ or a limb. Collins, 1 who 
has drawn an excellent portrait of this disorder, believes it to be closely 
allied to, if not identical with, urticaria tuberosa, or giant urticaria, 
and that its seat is in the vessels (vascular and lymphatic) traversing 
the corium, the swelling being the result of disturbance of the sym¬ 
pathetic nervous system. This disease is to be distinguished from the 
te blue oedema ” of hysteria (Sydenham), and from the “ white oedema- 
tous swellings ” of the same disease as observed by Charcot. [This 
disorder is also described in this work in connection with other oedema- 
tous affections of the skin.] 

Baker 2 reported a case of Urticaria tuberosa characterized by the 
presence in various parts of the body of persistent, yellowish-red tuber- 

1 American Journal of the Medical Sciences, November, 1892. 

2 Lancet, August, 1881, p. 153. 


INF LAMM A TIONS. 


173 


cles, which proceeded to ulceration. The parts most affected were the 
knuckles, the elbows, and the ears. These tubercles are said to have 
begun in a manner similar to that which characterizes the onset of 
evanescent urticarial wheals and tubercles. A somewhat similar case 
was observed by McCall Anderson. 1 

Urticaria, like erythema, may be either idiopathic or symptomatic; 
and in each the urticarial conditions may underlie or be superimposed 
upon almost every elementary lesion noted in the integument. The 
wheal may complicate (or be complicated by) the macule, papule, 
tubercle, vesicle, bulla, and pustule. It may spring from an excoria¬ 
tion or may result in a fissure. It is common in traumatisms, and is 
a prominent symptom in the skin bitten by insects, reptiles, or domestic 
animals. 

j Etiology. Idiopathic urticaria always results from the action of 
external irritants, the enumeration of which would require a recital 
of all the external agencies which are capable of injuring the skin. 
Prominent among them are the bites or stings of mosquitoes, lice, 
fleas, bedbugs, gnats, wasps, caterpillars, and bees. Contact with 
certain species of the jelly-fish is also effective. The wounds thus 
inflicted usually excite a stinging or a burning sensation, by which 
the patient is excited to rub or scratch the part. Then a wheal is 
rapidly formed at the site of the injury, and the irritation set up is 
conveyed to other parts of the skin in the vicinity, so that, especially 
in children, a single traumatism by an insect may excite an urticaria 
covering a much larger area. Many medicaments similarly operate, 
and it should be added that some of them, though applied externally 
without toxic effect to the mass of men, may produce urticaria in 
exceptional cases. Thus, a common flaxseed poultice when made to 
cover but a small portion of the body has produced violent symptoms 
of urticaria. The irritant action of the nettle (Urtica urens and U. 
dioica ) has given the malady its name. Climatic influences, more par¬ 
ticularly those in which the surface of the body is exposed to cold air, 
are very efficient in the production of urticaria, as also of bronchial 
asthma, with the symptoms of which the disease under consideration, 
in the case of adults, may often coexist or alternate. Mechanical 
violence, the application of leeches to the skin-surface, and surgical 
traumatisms may also induce the disease. 

Symptomatic urticaria is chiefly of the variety named by authors 
ab inge&tis, since it most frequently results from medicinal or from 
dietary articles taken into the stomach. Of the latter class may be 
named eggs, cheese, pork, sausage, coffee, tea, cocoa, confectionery, 
crabs, lobsters, clams, caviar (and several species of fish-roe), oysters, 
and fish generally, strawberries, cucumbers, skins of grapes, nuts, 
dates, raisins, almonds, figs, prunes, gooseberries, raspberries, canned 
fruits, meats, vegetables, oatmeal, pease, beans, onions, garlic, “ corn,” 
pickles, sauces, honey, mushrooms, pastry, salads, and spinach. Vin- 


1 British Medical Journal, December 8,1883. 


174 


DISEASES OF THE SKIN. 


egar, champagne, beer, and alcoholic beverages in general are capable 
of inducing a similar effect. 

Among the medicinal articles capable of inducing urticaria may be 
named the balsams, the turpentines, quinin, glycerin, chloral, valerian, 
arsenic, hyoscyamus, cinchonidin, salicylic acid and the salicylates, 
senna, santonin, and opium and its alkaloids. 

In the case of children and infants a severe urticarial efflorescence 
may be provoked by worms, or by any undigested morsel of food, 
or indigestible material of any sort that may have been passed into 
the stomach. Thus, a bit of orange-peel, or a fragment of potato¬ 
paring, or the skin of grapes, may be discovered to lie at the root of 
the trouble. In the case of adults, also, who have suffered from 
repeated attacks of urticaria, and have a fully developed sensitiveness 
of the gastro-intestinal tract, almost any unusual alimentary substance, 
if ingested, may induce a return of the disagreeable symptoms. 

It must be borne in mind that this undue sensitiveness to the effect 
of ingesta or external irritants is often an idiosyncrasy peculiar to the 
individual either on special occasions or at all times, and, given this 
susceptibility, that the effect is often great with a relatively insignifi¬ 
cant etiological factor. Thus, one may see cases in which a teaspoon¬ 
ful of beer, one grain of quinin, the smallest fragment of cheese, or 
but a single strawberry, will not only induce an urticarial rash of such 
extent as to cover the greater part of the surface of the body, but will 
also do the same on every occasion when the articles named are swal¬ 
lowed in the quantities given. The recognition of the fact that a small 
quantity of the article ingested can produce the rash is important to 
remember, as it is in general characteristic of the medicamentous erup¬ 
tions. The a prion reasoning, that the greater the quantity of the 
toxic agent applied or swallowed, the graver the effect, may lead to 
gross errors. It should always be remembered, in seeking the expla¬ 
nation for an urticarial rash, that the smallest amount of apparently 
innocent substances may be responsible for the largest annoyance. 

Other causes of urticaria may be cited, such as moral emotions (fear, 
shame, anger); pulmonary diseases, especially asthma; gastro-intestinal 
disorders, where ingesta play no part; intestinal parasites; malaria; 
the exanthematous fevers, particularly in their prodromal stages; dis¬ 
orders of the uterus, the kidneys, and the nervous centres; pregnancy, 
dentition, and the irregularities attending the menopause; and, lastly, 
the following special diseases: pemphigus, prurigo (of Hebra), rheu¬ 
matism, and purpura. 

Pathology. The wheal of urticaria is produced by an interchange 
of play between blood-vessels, muscles, nerves, and tissue, under 
the operation of a principle which the French term choo en retour. 
There is, first, most probably under the influence of the vaso-motor 
nerves, a clonic spasm of the capillaries in a limited area of the derma, 
by which is produced an acute oedema with some serous exudation. 
The rapidity with which this clonus occurs is greater than that with 
which the tissues of the vicinage can accommodate themselves to it,, 
either by imbibition or more diffuse tumefaction, and there results a 
counter-pressure upon the affected capillaries, by which their lumen is 


INF LAMM A TIONS. 


175 


still further restricted. As the wheal is not a purely fluid-containing 
nor yet an entirely solid lesion, but is semi-fluid in consistency, the 
mechanical pressure is greatest at its centre and least at its periphery. 
Thus are explained the white and relatively bloodless appearance of the 
centre of certain wheals, and their rosy or reddened outer border. 
The explanation is confirmed also by the fact that generally the most 
acute lesions, those springing into view most rapidly, are chiefly char¬ 
acterized by this whitened centre, while those more indolent or even 
chronic in their career, having been less subject to the interplay of 
the forces described above, permit of more general vascular injection, 
and have a light crimson or even at times a dull red centre. Wheals 
have been excised and microscopically examined by Neumann, Vidal, 
Poncet, and others, with the result of discovering merely evidences of 
dilatation and engorgement of blood- and lymph-vessels and infiltra¬ 
tion. According to Poncet, the lymph-vessels are also choked with 
u lymph-clots.” Rohe 1 explains the occurrence of the wheal by sup¬ 
posing that certain sensitive nerve-fibres of the skin possess also a 
vaso-motor function. 

The process described, occurring as an epiphenomenon after the 
traumatisms or other cutaneous lesions enumerated above, merely adds 
its characteristic symptoms to those previously apparent. 

Diagnosis. The diagnosis of classical urticaria is so readily made 
that the disease is often recognized before the attention of a physician is 
called to it. As usual, the atypical cases are those in which confusion 
may arise. The chief points to be remembered are : the rapidity of 
evolution of symptoms, their ephemeral duration, and the characteristic 
sensations they awaken. The action of the animal parasites and of 
insects not parasitic should not be overlooked, and the rash be closely 
examined for the minute wounds inflicted in this way, often covered 
with a minute pin-point- to pin-head-sized dried u blood-scale.” The 
various forms of erythema papulatum, tuberculatum, and nodosum are 
liable to be mistaken for urticaria; but this is in many cases inevitable, 
as intermediate forms between the two disorders are with difficulty 
assigned to either category. Absence of marked subjective sensations 
and persistence of lesions would generally point to an erythema, while 
marked prevalence of these symptoms would properly decide in favor 
of urticarial disease. 

In many cases the physician is consulted by a patient who gives a 
history of well-nigh intolerable distress at night or at other capriciously 
selected hours, and who repeatedly and vainly endeavors to exhibit the 
lesions as they appear upon the skin. Being examined on various 
occasions, scarcely a trace of cutaneous disorder is manifest. Here 
the practitioner has actually to decide upon the character of an eruption 
he never sees; the task is rarely difficult, no other than the urticarial 
eruption behaving in this fashion. Occasionally the physician will 
discover delicate, rosy, or deeper stained mottlings of the skin-surface 
where the wheals have been but are not. At times also he will suc¬ 
ceed, on the flexor aspect of the forearm, or in some situation where 


1 Maryland Medical Journal, May 15,1881. 


176 


DISEASES OF THE SKIN. 


the skin is equally delicate, in producing the appearance of one or 
more typical lesions by the aid of his finger-nail in scratching or by 
rubbing. These cases are more frequently of the chronic or at least 
of the relapsing class, and the victims of the disease may have a char¬ 
acteristic facies, a worn look from loss of sleep or from mental emotion. 
One is apt to discover in this class those who are mourning over the 
death of relatives, the loss of property, or separation from home and 
friends, and those harassed by anxieties. 

The several lesions of erythema are larger than those of urticaria, 
and they do not develop from characteristic wheals; in erythema mul¬ 
tiforme the lesions are far more persistent in type and do not provoke 
the characteristic subjective sensations of urticaria; in erysipelas the 
redness is characteristic and the swelling more diffuse. 

Treatment. Many cases of acute urticaria demand no treatment. 
The physician is summoned for a diagnosis. The patient and his 
friends are alarmed by the dread of variola or other severe affection, 
and learning that perhaps a pickled cucumber is alone responsible for 
the disorder, they wait with equanimity for the favorable conclusion 
which is always reached. Fortunately, the unusual, severe, and 
relapsing forms rarely begin with acute symptoms. 

Naturally, the first indication to be observed is the removal of the 
cause, and with this, if possible, accomplished, the next is the exclusion 
of all aggravating agencies. The discovery of the cause, at times 
readily effected, is often the most serious problem presented. An 
exhaustive and minute examination of the person and the history of 
the patient, a study of his food, drink, medicine, regime, clothing, 
sleeping-apartment, habits, occupations of life, and mental state, are 
here essential. When the disorder is recent, and is an urticaria ah 
ingestis , a brisk emetic or a cathartic may rid the stomach or the bowels 
of offending matters. This purgation done, it should be borne in mind 
that an idiosyncrasy of the patient may at this moment render the skin 
peculiarly sensitive to the action of other ingesta, and the diet, for a 
few days certainly, should carefully be prescribed. In many cases the 
alkalies are indicated by an acid condition of the stomach, and then the 
preparations of sodium, potassium, or magnesium are useful. Laxa¬ 
tives, such as rhubarb, magnesia, the cathartic mineral waters, and, in 
the case of children, small doses of castor oil are frequently indicated 
when there is no suspicion of irritating ingesta. At other times there 
is marked atony of the digestive organs, when the mineral acids, the 
bitters, and the ferruginous tonics may be needed. Again, lactopeptin, 
pepsin, or the subcarbonate or the subnitrate of bismuth may be 
exhibited with advantage for the relief of the indigestion which may 
be the prominent feature of the attack. 

Other remedies found useful in the internal treatment of urticaria 
are sulphurous acid in 1 drachm (4.) doses three times daily in sweet¬ 
ened water (Da Costa); copaiba; strychnin (Guibout); the arseniate 
of sodium, employed by Blondeau, in doses from (0.002) to 
(0.0013) of a grain; the fluid extract of ergot in \ drachm (2.) doses 
(Morrow); the sulphate of atropin, given by Schwimmer in doses of 
•gV (0.001) of a grain; and the salicylate of sodium in scruple (1.33) 


INFLAMMA TIONS. 


177 


doses. The latter drug has highly been praised by a number of writers. 
It is often given in 1 grain (0.06) doses every hour. Pilocarpin, or 
the fluid extract of jaborandi, is known to produce at times a powerful 
effect iu relieving surface-congestions of the skin by means of the 
excessive hyperidrosis it occasions, and in proportion to which it is 
produced the drug may become dangerous. 

Schwimmer endorses the following formula for this affection : 


U.—Atropise sulph., 
Glycerin., \ 

Aq. dest., J 
Gum. tragacanth., 
Ft. pil. No. xx. 


gr.*; 0 01 

aa ^ss; 21 

q. s.; M. 


The treatment of symptomatic urticaria should have regard also to 
that disorder of the viscera or of the general system to which the 
cutaneous symptoms may be attributed. Gout, as a not infrequent 
cause of the disease, should not be forgotten in advising treatment. 
The uterine complaint of a woman may require appropriate manage¬ 
ment, as also the diabetes of a patient with an affection of the kidneys. 
Quinin is indicated, of course, in periodical attacks, but its action in 
exceptional cases as a direct cause of urticaria should not be over¬ 
looked; the same, to a greater extent, is true of arsenic, the bromid 
and iodid of potassium, hydrate of chloral, and gelsemium. The 
larger number of patients are best treated without the employment of 
these drugs. 

In the local treatment of urticaria, with chief intent to assuage the 
disagreeable sensations experienced in the skin, the greatest diversity 
exists in the methods employed. This diversity is to be largely 
explained by the fact that a similar difference is to be noted in the relief 
experienced by different patients after the application of the same 
medicinal agent. Thus, cold- and hot-water baths, baths medicated 
by marine salt, aromatic vinegar, alcohol, cologne, camphor, the alka¬ 
lies, and sulphuric ether (compresses dipped in such solutions and laid 
over the part affected), douches and vapor-baths will, any of them, 
in the case of some individuals, produce a marked alleviation of symp¬ 
toms, and in others will be either inoperative or actually serve to 
aggravate the symptoms in the highest degree. Hebra asserts that 
several of the baths named above are quite useless, while Kaposi 
recommends cold lotions medicated with aromatic volatile substances. 
Fox prefers that alcohol, or cologne-water to which benzoic acid has 
been added, be dabbed over the part and permitted to evaporate. 
Hillairet and Gaucher employ in a similar way a solution consisting 
of one-third of ether and two-thirds of warm water. 

The alkaline bath should contain the carbonate of sodium, the bibo¬ 
rate of sodium, alum, or the bicarbonate of potassium, either singly 
or in combination in the strength of about 6 ounces (192.) of the salt 
to 30 gallons of water; 1 or 2 ounces (32.-64.) of the sulphuret of 
potassium may be substituted. The water is made demulcent by the 
addition of starch or of gelatin, or by immersing in it a muslin bag 
containing bran. When it is desired to employ the acid bath, \ an 
ounce (16.) of either muriatic or nitric acid is added to the quantity 


178 


DISEASES OF THE SKIN. 


of water given above. The bath of this size may also be medicated 
with 1 drachm (4.) of corrosive sublimate; or this drug may be used 
as a lotion in the strength of from \ (0.0016) to J (0.0033) a grain 
to the pint. Carbolic, benzoic, salicylic, boric, dilute hydrocyanic, 
and dilute nitric acids in weak solution are also employed with advan¬ 
tage in some cases. Other external applications are thymol, carbonate 
of ammonium, bromid of potassium, ether, chloroform, or chloral- 
camphor in the strength of J to 1 drachm (2.-4.) to the ounce (32.) 
of ointment. 

The ointment is prepared by rubbing together equal parts of cam¬ 
phor and chloral until a semi-liquid substance results. This prepara¬ 
tion is an antipruritic remedy of some value, but, if not largely diluted, 
will increase the uneasy sensations produced. In other cases an oily 
or fatty substance will give more prompt relief, especially if the 
eruption has been much irritated by scratching and it tends to persist. 
Among these may be named the linimentum calcis of the pharmaco¬ 
peia, and cold cream to which may be added fluid extract of Grindelia 
robusta, one part to twenty or thirty of vehicle. 

Mention should also be made here of the dusting-powders, which the 
reader will find described in the chapters relating to general therapeu¬ 
tics and the erythemata. They are the most cleanly of all external 
preparations in urticaria, and are often the only local measures required. 
With internal medication, as each case may suggest, the practitioner 
should be careful to note that the clothing of the patient is of a char¬ 
acter that will not aggravate the eruption, that sleep is secured without 
an excess of bed-covering, and that places where the temperature is 
for any reason elevated are carefully avoided by the patient, such as 
proximity to a fireplace or a droplight, heated places of amusement, 
the kitchen, etc. 

Among the Germans, sulphur, naphtol, and tar salves are employed 
in the management of the disease. 

One of the most effective and trustworthy of local applications in 
severe urticaria is a starch solution. The starch is first mixed with 
cold water, and is then boiled until the solution is of the consistency 
of thin mucilage. To each pint of this 1 drachm (4.) of the oxid of 
zinc and 2 drachms of glycerin (8.) are added before ebullition is com¬ 
pleted. When cool and applied to the surface this solution often gives 
prompt relief. The same is true of a thin solution of boiled oatmeal. 

Such is the empirical treatment of urticaria. It will be seen to be 
founded upon no rational method of procedure, because the very 
capriciousness of the disease demands and secures relief in one instance 
by a treatment which should be reversed in another. It must be 
admitted that cases occur in which all treatment seems absolutely value¬ 
less, often really injurious, to the patient. These cases will usually 
be found to be of the relapsing or chronic type. The subjects of this 
form of disease are often plunged into morbid mental states, dreading 
by day the exacerbations of the night, brooding over misfortunes expe¬ 
rienced or anticipated, worn by loss of sleep, fearful of a generous 
regime at the table. Here the treatment is largely moral, and demands 
the tact and courage of the physician. Travel, change of climate, 


INF LAMM A TIONS. 


179 


variation in the routine of life, new social surroundings, are here valu¬ 
able. The widow must be made to lay aside the heavy crape-veil 
beneath which her urticaria plays; the solitary patient must secure a 
companion capable of diverting the nervous attention for a few hours 
each day. 

It seems probable that to these efficient agencies must be in part 
ascribed the relief so often obtained at various mineral springs, both 
in America and abroad. Thus, the Karlsbad, Vichy, Saratoga, and 
White Sulphur Springs have all been credited with the production of 
beneficial effects in urticaria. 

Prognosis. The prognosis of an attack of urticaria is, as may be 
seen in what has preceded, exceedingly variable in different cases. 
Simple attacks of the acute sort are trivial, and in a few days the 
patient may retain but the slightest souvenir of the trouble. In the 
case of children, the attack is often at an end in the course of twenty- 
four hours. 

It should, however, never be forgotten that urticaria may torment 
the life of a patient to the utmost bounds of tolerance and seriously 
impair the general health. Persistent and rebellious chronic urticaria 
may prove to be a more formidable affection than a mild attack of 
syphilis. 


Dermatitis. 

( Ger ., Hautentzundung ; Fr., Dermatite.) 

Dermatitis is an affection of the skin characterized by the phenomena of inflamma¬ 
tion, including heat, redness, pain, and infiltration, terminating in resolution, 
suppuration, or the occurrence of gangrene. 

Inflammation of the skin occurs in a large number of cutaneous 
affections. Under this title, however, are grouped those inflammations 
in which the result is plainly due to a direct influence exerted upon the 
skin by thermal, chemical, or mechanical agencies. These inflamma¬ 
tions may be mild or be severe. 

The milder forms of dermatitis disappear without leaving behind 
them persistent lesions. The graver forms may terminate in gangrene, 
or may produce death by shock or by exhaustion. 

Dermatitis, then, is that idiopathic morbid state the phenomena of 
which are induced by the action of certain special agencies, such as heat, 
cold, poisons, and traumatism. The inflammatory process may involve 
the superficial or the deep portion of the integument, or it may extend to 
the subcutaneous tissues, or even deeper. The symptoms vary with the 
nature of the cause, the extent and degree of its influence, and the 
circumstances attending its operation. Hyperemia usually precedes 
the process, and it may be followed by a fluid or a plastic exudate, 
by the production of one or more of several recognized cutaneous 
lesions, by diphtheritic deposits upon the surface, or by gangrene. 
With these phenomena there may be general symptoms of mild or of 
severe grade, due to the influence excited by the local process upon 
the general economy. 


180 


DISEASES OF THE SKIN. 


[A] Dermatitis Traumatica. 

External violence, varying in character and severity, is capable of 
inducing dermatitis, the symptoms of which differ in degree, though their 
career is, in general, the same. In this list are included the inflamma¬ 
tions produced by surgical interference with the continuity of the integu¬ 
ment; excoriations caused by scratching, by the friction of garments 
and other articles injuriously acting upon the skin ; by the various 
implements handled in the trades; and by the bites or the stings of 
beasts, insects, reptiles, and fishes, when the result is traumatic and 
not toxic in character. These injuries may be in the form of con¬ 
tusion, blow, concussion, pressure, puncture, incision, or laceration, 
and the consequences are declared in heat, swelling, redness, and pain; 
in itching, burning, stinging, or pricking sensations; with subsequent 
inflammatory symptoms varying in grade from mild and transitory 
hyperemia and exudation to severe grades of inflammation with conse¬ 
quent production of pus, granulation, and repair; or gangrene, and 
separation of the slough; or, finally, by repair without cod sequences. 

[B] Dermatitis Venenata. 

Certain medicinal and other substances applied to the external sur¬ 
face of the skin are capable of exciting inflammation either by oper¬ 
ating as caustic, irritant, toxic, or even traumatic agents. The 
dermatitis is not necessarily limited to the surface with which the 
irritant has come in contact. The inflammation may extend to adja¬ 
cent portions of the skin, or, as a result of absorption with toxic 
effects or of reflex nervous irritation, it may appear on distant surfaces 
of the body. In this list are included most of the strong acids and 
alkalies, croton oil, cantharides, mustard, tartar emetic, mezereon, the 
compounds of mercury, arnica, turpentine, ether, chloroform, tarry 
compounds, resorcin; many of the dyes, several members of the rhus 
family ( Rhus toxicodendron , poison-ivy, and Rhus venenata , poison- 
sumach), the nettle, the smartweed ( Polygonum punctatum ), cowhage 
(Mucuna pruriens), and glass in fine powder or in delicate filaments, 
such as are thrust into the skin when handling certain articles of Vene¬ 
tian glassware. This list might indefinitely be extended, as there are 
few articles which are not capable of producing some irritation of the 
surface of the skin, if applied to it with sufficient vigor and for a 
certain period of time; and in some cases it is difficult to decide 
whether the effect is more traumatic or toxic. An almost equally long 
list of substances of animal origin might also be named having poison¬ 
ous effects upon the integument, such as decomposed or ammoniacal 
urine, feces, ichorous pus, and pathologically altered secretions from 
the uterus, the eye, ear, nose, etc. 

The symptoms of dermatitis venenata are substantially such as have 
already been described. Numerous types of cutaneous lesions—mac¬ 
ules, pustules, papules, vesicles, bullae, wheals, scales, crusts, free serous 
and purulent discharges, subcutaneous abscesses, and even gangrene 
with sloughing—may occur, the result being largely proportioned to 


INFLA MM A TIONS. 


181 


the character of the agent producing the injury, and to the susceptibility 
of the individual. 

A few of the more common sources of such accidents may briefly 
be considered. The use of soap for laundry, toilet, or other domestic 
purposes, containiug an excess of alkali, or even miuute particles of 
bone, is a frequent source of trouble, as are also several of the pro¬ 
prietary articles sold in the shops for similar employment. In these 
instances the erythema, vesiculation, infiltration, or other symptoms, 
will naturally be distinguished on the hands, or the hands and face. 
Stockings and other undergarments dyed with anilin, picric acid, chro¬ 
mium, or arsenic ; the leather lining of the inside of the hat or the cap, 
and the painted toys to which the lips of children are applied, will beget 
mischief in the various regions of contact for each. Dub ring reports 
cases where the dyestuff in the lining of shoes penetrated the material 
of stockings in women, and produced dermatitis of the feet or the 
legs. 

The tincture of arnica, an article unfortunately much used as a 
domestic application for contused and incised wounds of a simple char¬ 
acter, has produced very serious annoyance in some cases, two such 
having been recently presented at the author’s clinic. The number of 
these accidents is annually increasing. Cartier 1 reports excessive ery¬ 
sipelatous swelling, a phlyctenular eruption, and submaxillary adenop¬ 
athy resulting from the external use of arnica. Beauvais reported to 
the Paris Medical Society gangrenous results in one case. Buchner 
believes this poisonous action to be due to insects (particularly the 
Atherix maculatus) found in the calyx of the arnica-flower. 

Other native plants, a large number of which are enumerated in a 
valuable work by White, 2 presented in 1886, before the American 
Dermatological Association, are similarly effective. Wesener 3 reports 
that the Malacca bean-tree (Anacardium orientate) furnishes a caustic 
oil called “ cardol,” or u cardoleum pruriens,” that produces, after 
application to the skin, vesicles and vesico-pustules which contain 
cardol and terminate by crusting. He reports a generalized eruption, 
beginning on the face, due to this cause. 

The antiseptic dressings of modern surgery are at times responsible 
for eruptive troubles. Among these antiseptics may be named iodo¬ 
form, which has produced erythema, vesicles, pustules, aud wheals. 4 
Carbolic acid and corrosive-sublimate dressings have had similar effects. 
Many of the articles employed therapeutically by the dermatologist 
should be placed in the same category. Green, 5 of London, reports 
severe oedema of the skin followed by desquamation, resulting from 
the application to it of the ointment of ammoniacal mercury in the 
strength of 2 drachms (8.) to the ounce (32.). 

Leszinsky reports a case of dermatitis over the face following the 
use of a “ triple extract of heliotrope” as a toilet-preparation. 

An exceedingly common source of such dermatitis is urine retained 
upon underclothing of adults. A persistent dermatitis of the scrotum, 

1 Lyon Med., April 13,1884. 2 Dermatitis Venenata, Boston, 1887. 

3 Deutsche Arch. f. klin. Med., vol. xxxvi. p. 578. 

4 See paper of Dr. R. W. Taylor, read to the New York Academy of Medicine, 1887. 

6 British Medical Journal, May 3,1884. 


182 


DISEASES OF THE SKIN . 


the perineum, or the inner faces of the thighs, in either sex, always calls 
for a careful examination as to whether a few drops of urine are not 
left in contact with such underclothing after each act of micturition. 
Fistulse, urinary incontinence, prostatic disease, “stammering of the 
bladder / 7 imperfect finish of the coup de piston in men, especially after 
a gonorrhea, and similar troubles, are all to be remembered. 

The Eruption due to Ivy-poison. The eruption produced 
by the poison-ivy and other varieties of rhus is almost exclusively 
an American disease; and from its frequency in the United States 
has attracted a great deal of attention. A certain degree of suscep¬ 
tibility to the poisonous action of the plant is requisite for the pro¬ 
duction of its effects, as some individuals can handle the leaves of 
the plant with impunity, while others, it is claimed, are affected 
by its exhalations within a circle having a radius of several feet. 
It is, however, difficult to demonstrate the truth of the last state¬ 
ment, suspecting, as one may, that such instances are usually cases 
of contact with other than the suspected plant. The parts commonly 
affected are the hands and the regions to which the latter are carried, 
such as the face, the genitals, the arms, the thighs, and the neck; bare¬ 
footed children suffer in the feet and the legs. Usually the symptoms 
are developed in the course of a few hours, and they consist of erythe¬ 
matous patches, scanty or profuse vesiculation with abundant, serous 
weeping after rupture of the lesions, swelling, oedema, and disfigure¬ 
ment, and intense burning and itching sensations. Serious effects are 
occasionally produced. Deeply attached scars may result from sub¬ 
cutaneous abscesses of parts greatly swollen. Occasionally, in par¬ 
ticularly sensitive skins, the eruption spreads from the skin-surface 
affected by the poison to that where presumably none has been ap¬ 
plied. It should be remembered, however, that articles of clothing 
may, for brief periods of time certainly, furnish sources of further 
trouble, being worn at the moment of contact with the plant, then laid 
aside, and, the occasion quite forgotten, being subsequently employed. 
Thus, a pair of undressed-kid gloves after lying for two weeks 
untouched have sufficed to reawaken the disease. 

A number of cases of dermatitis have originated in some parts of 
the Orient from contact with the varnish employed in the finishing of 
lacquered ware. This lacquer is manufactured from the rhus varnish. 
A few instances of such dermatitis have occurred in America from 
handling newly imported articles of this class. 

Careful observation of a typical case of dermatitis, soon after the 
onset of symptoms, will disclose the exact surface of contact, each 
surface being delicately outlined by a reddened, tolerably well-defined 
line, within whose limitations will be seen a slightly tumefied, erythe¬ 
matous surface, at times displaying closely packed, pin-point-sized 
papules, which may be embryonic vesicles, or which may proceed to 
resolution without serous effusion. 

The diagnosis of the eruption will be aided by recalling the features 
described in a careful monograph on the subject by White, of Boston . 1 


1 New York: D. Appleton & Co., 1878, from the March number of the New York Medical 
Journal of the same year. 


INFLAMMA TIONS. 


183 


According to this author, the lateral surfaces of the digits first exhibit 
the symptoms of the eruption, later the dorsal surfaces, and latest 
the thickened palms. The efflorescence also is more irregularly dis¬ 
tributed, more uniformly vesicular, and the vesicles less transparent 
than in eczema. The lesions, moreover, are more vesicular and less 
papular at the outset, and, though suggesting papules by their situation 
in the palm, are in that situation readily made to exude serum by 
puncture with a needle. 

Treatment. Internal medication is not required. The local treat¬ 
ment is that of acute eczema. The application of an alkali, for the 
purpose of neutralizing the poisonous volatile alkaloid in the leaves of 
the plant (toxicodendric acid, Maisch) should evidently be considered 
solely with a view to prophylaxis, as it is difficult to understand how 
such neutralization can control the inflammatory process after its 
onset. Black wash, solution of sugar of lead, or oleated lime- 
water, should be employed at first, and be followed later by dusting- 
powders. The late Prof. Babcock, of Chicago, a frequent sufferer 
from this disease following his extended botanical excursions, first 
taught the value of an ointment made by incorporating a decoction of 
the inner bark of the American spice-bush [Benzoin odoriferum) with 
cold cream. It certainly has afforded very prompt relief in the cases 
in which one is able to employ it, the difficulty lying in securing the 
bark of the shrub in its young and tender state. 

A long list of topical remedies have been vaunted as specific for the 
relief of this disorder, from the brine of a pork-barrel to a decoction 
of the leaves of the plant itself. As the eruption subsides with satis¬ 
factory results when the skin is protected and not irritated by the local 
treatment,it is not difficult to explain these facts. In this way corrosive- 
sublimate lotions; the tincture of iron; bromin, 15 drops to the ounce 
(32.) of olive oil (Brown); dilute nitric acid; hyposulphite of sodium; 
bicarbonate of sodium; saturated solutions of chlorate of potassium; 
and Grindelia robusta, 1 drachm (4.) of the fluid extract to 8 ounces 
(250.) of water, have each been found useful. 

[C] Dermatitis Calorica. 

Under this title are included those affections of the skin induced by 
extremes of thermal variation. 

Unduly high temperatures produce in the skin some redness and a 
slight degree of swelling, the color not completely disappearing under 
pressure. If the exciting agent be withdrawn before further effects 
are induced, the color first deepens, then becomes paler, and in twenty- 
four hours the process is usually concluded with a very delicate and 
transitory resulting pigmentation. 

Bays of heat and heated objects at a temperature from above 125° 
to 175° F. produce immediately, or after a brief interval, first, an 
erythema, which disappears when the source of the heat is removed; 
second, after more prolonged exposure, the symptoms of active inflam¬ 
mation and exudation. Vesicles or bullae, isolated or confluent accord¬ 
ing to the severity of the cause, may rise from a reddened skin which 


184 


DISEASES OF THE SKIN. 


is usually intensely painful. These lesions are persistent or are transi¬ 
tory, and are generally filled with a clear serum, which exudes and 
dries into crusts after rupture of the chamber in which it was im¬ 
prisoned. At other times the serous exudation is so great that the 
epidermis rises in broad plates, from beneath which the serum is 
exuded. This process may terminate by a free production of pus upon 
the surface and gradual resolution. Adenopathy is a frequent concom¬ 
itant symptom. In such dermatitis of extensive areas of the skin 
the intensity of the process may awaken a violent fever, or death may 
result from shock or exhaustion. 

In yet severer grades there is the production of an eschar, which is 
dry, brown, blackish, and destitute of all signs of vitality; or, as 
Kaposi describes it, is dense, coriaceous, and white as alabaster, though 
upon the eschar some vesicles appear, and by their presence suggest 
a false conclusion as to the vitality of the 'tissues upon which they 
rest. In from eight to ten days the eschar is removed by suppurative 
processes, and the scene is closed by the usual phenomena of granula¬ 
tion and cicatrization. The characteristics of the scar thus produced 
are: its great irregularity, its tendency to stellate radiation, and the 
production of ridges, folds, pockets, and bridles. 

Burns involving one-third the body-surface are of grave portent, 
and those affecting one-half the body are generally fatal, even though 
for from twenty-four to forty-eight hours there may be little complaint 
of pain. The causes of death in these fatal cases are often obscure, 
as the post-mortem results are usually negative. Gastric and duodenal 
ulceration, however, is often recognized. Overheating of the blood, 
heart-paralysis, oligo-cythemia, and actual destruction of leucocytes 
have all been supposed to be effective in bringing about dissolution. 
In cases where life is prolonged to the third day the complications of 
pyemia, erysipelas, and tetanus may arise. Lastly, exhaustion fol¬ 
lowing fever, suppuration, hemorrhage, and visceral affections may 
lead to fatal results. 

Treatment. In the treatment of the simplest burns, rest, lotions of 
lead-water, and cool water with the application of compresses, are 
usually sufficient to secure relief; occasionally, dusting-powders may 
advantageously be substituted. In the cases where serum is invited 
rapidly to the surface, with the production of vesicles and bullae, the 
latter should gently be punctured to give relief to the tension by the 
evacuation of their contents, but the roof-wall should be preserved, 
as it may subsequently form an attachment to the exposed derma 
beneath. The indications then are to exclude the air as perfectly as 
possible and to prevent suppuration, indications which are admirably 
met by the application of carbolated oil and lime-water with the Lister 
dressing. Continuous immersion in water of the temperature most 
agreeable to the patient, as practised by Hebra in cases of severe and 
extensive burning, produces a speedy and certain amelioration of the 
pain and a favorable condition of the wounds, though it does not avert 
a fatal issue in any dangerous case. 

The strictest antiseptic precautions are demanded when the suppura¬ 
tive process in the skin is both active and extensive. Disinfection 


INF LA MM A TIONS. 


185 


with a 5 per cent, solution of carbolic acid, or a 2 per cent, resorcin 
solution, should be followed by the application of protective silk wet 
with a o per cent, solution of the sodic biborate, or of sodic bicarbon¬ 
ate, and the whole enveloped either in borax-lint, antiseptic (mercuric 
iodid) wool, carbolized gauze, or salicylated cotton; over all, imper¬ 
meable rubber tissue should be wrapped. 

.Nitzsche 1 first disinfects the burnt surface thoroughly with carbolic 
acid, having previously protected the blebs, after which it is covered 
with a thick varnish of linseed oil and litharge mixed by the aid of 
heat with 5 per cent, of salicylic acid. When this coat is dry, a 
second coat is applied, and the whole is finally covered with a thick 
layer of wadding retained in place by an elastic bandage exercising 
moderate compression. Cicatrization progresses beneath the dress¬ 
ing without changing the latter. When suppuration occurs the upper 
layer of the wadding is removed, and dried salicylic acid in powder is 
sprinkled over the surface, the wadding being afterward reapplied. 

Skin-grafting may be required to cover the extensive ulcers left by 
the larger burns. 

In Congelatio, or dermatitis from congelation, there are also, 
usually in the milder forms, circumscribed erythematous patches or 
plaques, generally recognized under the name of Pernio, or chilblain, 
seated upon the digits or, more rarely, upon the face, and occasioning 
a disagreeable sensation of heat, smarting, or itching, especially after 
the chilled part has again been warmed. 2 Chilblains are bluish or 
purplish-red in color, and are often seated on a slightly oedematous 
integument. They are often cool to the touch, when subjectively hot. 
Authors have claimed that anemia is a chief predisposing cause of the 
complaint, but it frequently occurs in perfectly healthy young people. 
Sir Erasmus Wilson has suggested that some cases of so-called “ lupus 
erythematosus ’ ’ of the hands belong to this category. 

In the second grade of inflammatory reaction, following the state of 
contracted blood-vessels and pallid integument produced immediately 
by the action of cold, bullae and vesicles form, with, in severe cases, 
underlying ulcers. 

In the third grade gangrene may occur, with and without the forma¬ 
tion of bullae. The frozen part may become insensitive, white, aud 
cold, without the circulation in it of blood- and lymph-currents. From 
this condition reaction occurs, with the formation of an eschar, differ¬ 
ing in depth according to the severity of exposure to cold. If, 
however, over and beyond the interference with the circulation, the 
tissue itself has been destroyed, when reaction occurs the part falls at 
once into gangrene; or there form bullae larger than those described 
above, filled with sanguinolent serum; or the skin is smooth, marbled 
with bluish lines, whitish, cold, and insensitive. Mortification ensues, 
followed by the well-known phenomena of the u line of demarcation,” 
and, in favorable issues, suppurative separation of the dead part, 
granulation, repair, and cicatrization. As the injuries induced by 
congelation are more frequent upon the extremities, the bones largely 


1 Deutsche med. Zeit., 1881. 


2 Consult the chapter devoted to the Erythemata. 


186 


DISEASES OF THE SKIN. 


participate in the losses of tissue, especially those of the digits. 
Septicemia and a fatal result may follow. 

Chilblains are internally treated by the ferruginous tonics, particu¬ 
larly the tincture of iron; externally by stimulant applications, such 
as those containing iodin, camphor, carbolic acid, tincture of benzoin, 
and balsam of Peru. Kaposi recommends: 


R.—Pulv. camphorse, 
Cretse prseparat., 
01. lini, 

Balsam Peruvian., 


gr. x; 

J.v 

; 

TTlxx; 


50 

32 

64 

1 M. 


Frictions, with or without medication, are generally useful. The 
parts are to be carefully protected from pressure and undue friction- 
effects. 

Dilute nitric acid and peppermint water in equal proportions, painted 
over the part for three or four successive days, have been recommended 
by Lapatin for the treatment of frost-bitten fingers and toes. Hydro¬ 
chloric and pyroligneous acids, lemon-juice, collodion, and acetate of 
lead, both in lotions and poultices, are also recommended. Meurisse 
advises in the management of both severe ambustio and congelatio that 
goldbeater’s skin be employed over any salves or lotions applied to 
the affected surface. 

In cases of severe congelation the circulation is to be cautiously 
restored by friction performed in an apartment the air of which is cool, 
to prevent too energetic reaction. Friction with snow is employed with 
safety in America and in the steppes of Russia, where these accidents 
are frequent and are grave in results. Perseverance for hours in this 
course is often rewarded with success in apparently desperate cases. 
Antiseptic dressings are usually demanded when sloughing and ulcera¬ 
tion ensue. 


[D] Dermatitis Medicamentosa. 

The importance of recognizing the fact that a given eruption is pro¬ 
duced by an ingested drug can scarcely be overestimated from the point 
of view of the diagnostician. The errors committed in this connec¬ 
tion are so frequent and so annoying to the patient that it is necessary 
for the physician to inquire very carefully, before treating any cutane¬ 
ous disease, as to the medicaments previously swallowed by the patient, 
and also to be prompt to connect any aggravation of a cutaneous disease 
with remedies ordered by himself for internal use. The following is 
but an imperfect list of the drugs whose internal administration may 
be followed by an exanthem—imperfect, because without question 
many have yet to be recognized as possessing such an action. As to 
the modus operandi of such medicinal agents, for the most part our 
knowledge on this subject is purely conjectural. Some, for example, 
the iodid of potassium, are eliminated in part by the glands of the 
skin, and presumably have thus a local effect upon such emunctories; 
others, and in this class, the author believes, should be included quinin, 
induce an urticaria scarcely to be distinguished from an urticaria ab 
ingestis. Some operate, possibly, in either or in both ways at different 


INFLAMMA TIONS. 


187 


times . or in different individuals. The absurdity of supposing that 
any disease can be u driven out ” by the ingestion of such drugs should 
be relegated to the specious ignorance which first framed such an 
hypothesis. 1 

Acids. The acids capable of producing macules, papules, erythema, 
desquamation, etc., are carbolic, nitric, tannic, benzoic (and benzoate 
of sodium), and boric (and borate of sodium). 

Modadewkow reports a case in which the pleura was washed out 
with a 5 per cent, solution of boric acid, a part of which was not 
removed. There occurred as a result an erythematous rash over the 
face, the trunk, and the extremities. 

Aconite. This drug is said to be productive at certain times of 
marked diaphoresis with the occurrence of vesiculation and considerable 
itching. The diaphoresis in an irritable skin may be responsible for 
the trouble. 

Antipyrin and Other Remedies of its Class manufactured 
by the action of glacial acetic acid upon the petroleum-products. Ernst 2 
has been followed by many observers in recording rashes resulting from 
the administration of antipyrin. The symptoms are discrete and con¬ 
fluent patches of bright red, scarlatiniform, erythematous, and pruritic 
macules or papules. Veiel 3 reports oedema with bullae upon the lips 
and toes, and over the palate, with urticarial lesions of palms and 
soles, after ingestion of antipyrin. Brocq, Darier, and others have 
reported cases in which antipyrin has produced a more or less per¬ 
sistent erythema in the form of isolated, scattered, sharply defined 
plaques. These plaques are usually few in number and they tend to 
return in the same sites whenever the individual takes antipyrin. The 
redness and pigmentation may persist several weeks. Wickham reports 
an antipyrin rash which simulated perfectly a macular syphiloderm. 

Arsenic. Erythematous, vesicular, papular, and much more rarely 
pustular, bullous, and ulcerative lesions occur upon the face, the back, 
and the hands after the ingestion of arsenic. The well-known effects 
of the administration of the drug in toxic doses upon the mucous 
membranes of the eyes, nose, and mouth, need not be described in this 
connection, nor yet the grave, gangrenous symptoms, with osseous 
necrosis, that have been observed in workers in the metal. 

A bright red, scarlatiniform blush with a few isolated vesicles has 
covered both shoulders of a young woman with a delicate skin after 
taking three medicinal doses of Fowler’s solution, the eruption being 
present, but less distinct upon her face and hands. In two cases the 
rash in polymorphic type was limited to the hands alone. 

Young patients who have taken arsenic in the largest medicinal 
doses for relief of chorea often present as a result a dark discoloration 

1 For full details of this subject, consult the admirable treatise on Drug Eruptions, by Dr. Prince 
A. Morrow (New York, 1887). 

2 Centralb. f. klin. Med., 1885. 8 Arch. f. Derm. u. Syph.. 1891, Hft. 1. 


188 


DISEASES OF THE SKIN. 


chiefly of the skin of the chest and the neck, but also of other parts 
of the body. This discoloration is suggestive of the bronzing seen 
in Addison’s disease. In some instances there are no other cutaneous 
symptoms. Guaita and Liege noted these phenomena, usually in the 
fifth month after ingestion of the drug. Cases are reported in which 
long-continued use of arsenic has produced keratosis of the palms and 
soles. 

By far the largest number of rashes are, however, produced in per¬ 
sons previously suffering from the cutaneous disease for the relief of 
which the drug is administered. Here the toxic effect is declared by 
either—first, increased hyperemia of the skin, visible in an erythema¬ 
tous patch, or beneath the scales of a squamous patch, or as an areola 
of bright red hue about any aggregation of lesions; secoud, by simple 
aggravation of the type of a disease already in existence (recurrence 
of acuity in a subacute eczema); third, by rapid peripheral extension 
of a disease which had previously been well limited in contour; fourth, 
by converting a disease exhibiting uniformity of lesions into one char¬ 
acterized by multiformity. Each of these results might be illustrated 
by cases. 

In a series of eight cases of poisonous effects produced by arsenical 
paper-hangings, and reported by Brown, 1 there ivere, curiously, no 
cutaneous symptoms. 

Belladonna. The well-known erythematous, scarlatiniform, or 
reddish efflorescence produced by belladonna and its alkaloids is usually 
limited to the upper segment of the body, but it may become general¬ 
ized. It is said to occur more frequently in children, probably because 
it has been administered largely to individuals of that age under the 
superstition that it is useful as a prophylactic in scarlatina. Very dis¬ 
agreeable and even dangerous results have followed the instillation into 
the eye of atropin as a mydriatic, the rash being accompanied by con¬ 
stitutional symptoms. 

Bromin and its Compounds. A full and valuable account of the 
cutaneous effects of bromin and its compounds, when administered 
internally, is contained in a paper on medicinal eruptions, read in 
1880, by Van Harlingen, of Philadelphia, before the American Der¬ 
matological Association. Acneiform lesions, pustules, macules, maculo- 
papules, papules, eczema-form moist patches, furuncles, urticarial 
wheals, scales, and ulcers have been induced by swallowing the bromids 
of potassium, sodium, ammonium, and lithium. By far the commonest 
are the acneiform and pustular lesions, occasionally accompanied by 
pruritus, which appear upon the face and the upper portion of the 
trunk, though the rash may be very distinct upon the genital region. 
Duhring reports an interesting observation of a patient in whom the 
eruption simulated very closely the maculo-papular syphiloderm, the 
patient having taken a bromin salt for three years. The eruption 
first appeared within five or six days after decreasing the dose. Kaposi 


1 Paper read before the Boston Society for Medical Observation, March 6,1876. 



INF LAMM A TIONS. 


189 


observed a case of bromid rash in a nine-months-old suckling, the 
mother having taken 120 grammes of the bromid of potassium in two 
months, herself exhibiting no traces of eruption. 

A remarkably characteristic exanthem is produced by the admin¬ 
istration of bromid of potassium, especially to infants and young 
children. The lesions are condylomaform, quite numerous, conspicu¬ 
ous about the face and neck, where they are packed closely together, 
but they are also seen on other parts of the body. The small coin- 
to nut-sized elevated nodules are usually flattened ; and to a degree 
they resemble carbuncles, as they have a cribriform summit where 
multiple points of imprisoned pus are visible. This rash, though 
rare, has been carefully studied and well illustrated by chromolitho- 
graphic reproductions. 

T. C. Fox and Gibbes report these condylomaform nodules in the 
case of an infant where the histology of the lesions was carefully 
studied; and Fay, in a child eleven months old, also recognized an 
exanthem which had been mistaken for molluscum epitheliale. These 
lesions are very similar to the condylomaform rash seen in children 
after the administration of the iodid of potassium. 

Browse, of Cambridge, England, recommends for relief of these 
symptoms the application of a solution of salicylic acid, 1 grain to 
the ounce (0.066-32.) of water, frequently applied on lint, having 
successfully treated in this way sores as large as the palm of the hand. 

Cannabis Indica. The only instance thus far reported of an erup¬ 
tion produced by the ingestion of this drug was observed by the author 
in the case of an adult male, who was extensively covered with papulo¬ 
vesicular lesions after swallowing a grain (0.066) of the extract. 1 

Chloral. An erythematous rash is the commonest of the eruptions 
produced by chloral, though wheals, red and yellowish papules, vesi¬ 
cles, pustules, and petechial blotches have been observed. The rash 
occurs upon the face, the neck, the trunk, and the limbs, of the latter 
especially on their extensor surfaces. In a man of advanced years and 
totally deaf, who had slept only under the influence of chloral for four 
years, the author observed discrete scaly patches as large as saucers over 
the hands and the lower extremities. 

Martinet 2 reports an erythematous and scarlatiniform rash, occasion¬ 
ally commingled with urticarial and purpuric lesions, occurring upon 
the face and neck, the front of the chest, the extensor surfaces of the 
larger joints, and the dorsum of the hands and feet. There was no 
pyrexia nor indisposition, but in some cases there were dyspnea and 
cardiac palpitation. 

Cod-liver Oil. According to Farquharson, 3 cod-liver oil after 
being swallowed is capable of producing an acne. This result can be 
true only of very inferior qualities of the oil, such as are not rarely 
found in the English market. 


1 New York Medical Record. May 11,1878. 
3 British Medical Journal, Feb. 22,1879. 


2 Th£se de Paris, 1879. 


190 


DISEASES OF THE SKIN. 


Copaiba and Cujbebs. The ingestion of copaiba is occasionally 
followed by a vividly red rash, in the form of discrete macules, more 
rarely maculo-papules, invading chiefly the lower segments of the 
extremities and the skin of the belly, but often completely covering 
the body-surface. The rash may occur in dark mulberry-red petechiae, 
and is always accompanied by pruritus. Inasmuch as the drug is 
often administered for the relief of a venereal disorder not syphilitic, 
care should always be taken not to confound the eruption it may excite 
with the early macular syphiloderm. Cubebs is much more rarely 
followed by a similar result. 

Condurango. Guntz 1 reports the occurrence of furuncular and 
acneiform lesions in twenty patients out of one thousand who were 
taking condurango for the relief of syphilis. 

Digitalis. In Behrend’s treatise on diseases of the skin 2 reference 
is made to cases where macular and maculo-papular rashes succeeded 
the ingestion of digitalis. 

Iodin and its Compounds. The iodid of potassium is responsible 
for the larger number of all eruptions among medicinal rashes. The 
frequent employment of this drug and the very marked influence it 
possesses over the skin render the study of these morbid results im¬ 
portant. Unlike many of the other substances in the list of drugs, 
the iodin compounds are followed by some species of rash in probably 
the larger number of all persons who swallow them. 

The resulting lesions may be macular, papular, vesicular, bullous, 
pustular, petechial, multiform, or in the form of circumscribed, sub¬ 
cutaneous abscesses. In appearance the rashes produced by iodin and 
its compounds may simulate those of every other dermatitis. 

The macular rash is best seen fully developed over the upper extrem¬ 
ities in discrete erythematous patches or in a diffuse blush. Generally 
the rash is displayed symmetrically. The hands are often affected, 
and suggest in appearance the dyed hands of the anilin-worker. The 
rash assumes at times the papular type, with special production of 
papules upon the face. 

Berenguier describes a scarlatiniform rash of sudden occurrence upon 
the surface of which were numerous minute discrete vesicles. Eczema- 
form eruptions with abundant serous exudations are also reported. 

A number of interesting cases are on record where the administra¬ 
tion of the drug was followed by the production of bullse. Bumstead, 
Taylor, Duhring, Tilbury Fox, Finny, and the author have de¬ 
scribed such bullae in adults as well as in children. 3 Hallopeau 4 also 
reports a case in which a bullous eruption followed the ingestion of 
the idodid of potassium. The patient died, and the post-mortem 
appearances were reported in full. The eruption occurred chiefly 
about the head and neck, and the upper extremities. The significant 
rarity of vesicular and bullous lesions in acquired syphilis indicates 

1 Vierteljahrschft. f. Derm. u. Syph., 1882. 2 Braunschweig, 1879. 

3 Arch, of Derm., October, 1870. Journal of Cutaneous and Venereal Diseases, 1886, n. 383. 

4 Union M6d., March 25,1882. 


INF LAMM A TIONS. 


191 


that at least some of the cases on record were those of rashes induced 
by the remedy given for relief of the disease. 

A careful analysis of these bullous rashes leads to their division into 
three categories: first, those occurring, often with fatal results, in 
cachectic adult patients; second, those occurring as part of the eruptive 
lesions in a polymorphic group; third, those occurring in well-nour¬ 
ished children, and taking on the appearance of molluscum epitlieliale 
and condyloma lesions, usually compounded of papulo-vesicles and 

Fig. 42. 



Papilloma, due to the ingestion of the iodin compounds. 
(From a painting in oil.) 


pustules. Erythanthemata of a similar type have also been recognized 
in infants after the ingestion of bromid of potassium. 

The pustules induced by the administration of iodin compounds are 
seen chiefly upon the face, the neck, the trunk, and the arms. They 
are usually seated upon a firm base, and may be followed by cicatrices. 
Duhring has seen an annular patch upon the forehead, made up of 
minute vesico-pustules, which eventually developed into a globular 




192 


DISEASES OF THE SKIN. 


violaceous mass, nearly two inches in diameter. Large cherry-sized, 
tubercular or papillomatous elevations abruptly arising from the surface 
of the integument may present a cribriform structure, which shows the 
open ducts of several suppurating follicles (chin, cheek, nose). A few 
cases are reported in which fungating tumors were found, producing 
an appearance almost identical with that of mycosis fungo’ides. 

The purpuric rash occurs in petechial macules, discrete and miliary, 
situated chiefly on the lower extremities. In a case reported by Mac¬ 
kenzie (quoted by Van Harlingen) a single dose of 2J grains (0.166) in 
an infant was followed by a fatal result after the petechise appeared. 

Jaborandi and Pilocarpin are capable, when ingested, of inducing 
free diaphoresis; erythematous macules, wheals, and pin-head-sized 
papules have been seen upon the surface as a result. 

Mercury. The statement that mercury when ingested is capable 
of producing an erythematous rash upon the surface of the skin is 
made by several reputable authors. In view of the fact that the metal 
has been, in its various compounds, administered for so long a period 
of time, and for so many various diseases without the production of 
cutaneous symptoms, it is a fair hypothesis that the few reported cases 
are those in which there was coincidence rather than causation. After 
observation of a large number of individuals in whom this drug has 
both properly and very injudiciously been employed for long periods 
of time, one may not be able in a single instance to discover any evi¬ 
dences upon which to base a belief in its power to produce a cutaneous 
exanthem. A similar statement was made by White, of Boston, when 
this subject was under discussion in the American Dermatological Asso¬ 
ciation. Mercurials, when applied to the external surface of the body, 
are, as is well known, capable of exciting, in various degrees, cutaneous 
irritation and inflammation. 

Opium and its Alkaloids. Erythema, wheals, and occasionally 
intense pruritus, with oedema, and subsequent desquamation, have 
followed the ingestion of opium and several of its alkaloids, notably 
morphin. In its mildest expression this cutaneous effect is limited 
to a characteristic itching about the nostrils that can be perceived 
in a large proportion of all patients as soon as the general effect 
of the opiate becomes apparent. In some patients there may fol¬ 
low an intense and distressing general pruritus without efflorescence, 
and it is certain that the subsequent urticarial efflorescence is caused 
by the free diaphoresis which the medicament induces. This fact 
is a matter of some practical moment, as the use of an anodyne for 
the purpose of procuring sleep for a patient tormented with a noc¬ 
turnal pruritus would seem to be occasionally indicated. Inasmuch 
as chloral, the bromid of potassium, and the opiates are all capable 
of aggravating such distress, great caution is needful in such emer¬ 
gencies. In general, it may be said that the employment of these 
and similar remedies for the relief of pruritus should be interpreted 
as a confession of weakness on the part of the physician, who ought to 


INF LAMM A TIONS. 


193 


be able to alleviate the distress of his patient by a judicious employment 
of topical remedies. 

Petroleum and its products are responsible for a large list of medic- 
amentous rashes. 

Phosphorus. Hasse (quoted by Van Harlingen) cites the case of 
a young girl who exhibited a pemphigoid rash after the ingestion of 
phosphoric acid. According to Farquharson, 1 phosphorus itself is occa¬ 
sionally responsible for purpura with gastro-intestinal derangement and 
jaundice preceding a fatal issue. 

Podophyllin. Winter burn 2 reports that those who work in resi- 
noid podophyllin are liable to suffer, as a consequence of this exposure, 
from a cutaneous disease of the scrotum. 

Potassium Chlorate. Stelwagon and others report that papules 
and macules have followed the use of this remedy, administered in 
the form of tablets. 

Quinin (Cinchona) and its Alkaloids. Morrow 3 collected, in 
an interesting paper, the record of over sixty cases of quinin-exanthem, 
and he shows that its prevailing type is exanthematous, the rash being 
of a vivid hue, disappearing on pressure, and resembling scarlatina. 
Other lesions produced are wheals, papules, vesicles, petechise, hemor¬ 
rhagic purpura, bullae, and, in one instance, an intense localized der¬ 
matitis with beginning gangrene of the scrotum. In some of the cases 
the rash reappeared on repetition of the dose, and even after recourse 
to the other alkaloids. The subjects were mostly women. As with most 
of the other exanthem-producing drugs, small doses, where the idio¬ 
syncrasy existed, sufficed for the effect. The rash has been studied 
in an adult male, who, after taking 2 grains (0.133) of the sulphate of 
quinin for the first time in six years, exhibited an efflorescence (over 
the entire surface of the body) of discrete, finger-nail-sized, salmon- 
and pinkish-tinted, scarcely elevated patches, accompanied by a mod¬ 
erate pruritus. A repetition of the dose was followed by a recurrence 
of the exanthem. 

In several cases desquamation is reported as resulting from the rash. 
As to the occurrence of the general symptoms recognized under the title 
of “ cinchonism ” (tinnitus aurium, etc.), these may and may not 
accompany the lesions. Morrow makes the pertinent suggestion, in 
view of the frequent similarity of the rash to that exhibited in scarla¬ 
tina, that many cases hitherto recorded as recurrent attacks of that 
disease and measles, with other anomalous cutaneous eruptions, may 
have been instances of the quinin-exanthem. 

Salicylic Acid and the Salicylates. Reports of cases where 
these substances after ingestion have produced cutaneous symptoms 

1 Loc. cit. 2 Louisville Medical News, April 21,1882. 

3 New York Medical Journal, March, 1880, p. 244. 

13 


194 


DISEASES OF THE SKIN. 


have been made by Heinlein, Wheeler, and Freudenberg, all cited by 
Van Harlingen. The symptoms were diffused redness, urticarial 
lesions, vesicles, pustules, petechiae, and vibices, accompanied by 
intense pruritus, and followed by desquamation. 

Santonin. A generalized eruption of urticarial lesions seated upon 
a reddened surface and accompanied by oedema is reported by Sieve- 
kins: as occurring: in a child to whom santonin had been administered 
as a vermifuge. 1 

Sodium Benzoate. Roh6 2 reports two cases in which an erythe¬ 
matous rash, with well-defined border, accompanied by itching and 
slight desquamation, occurred during the use of the benzoate of sodium. 
The patients were a woman, aged thirty-five years, and a boy with 
diphtheria. The eruption disappeared on the discontinuance of the 
remedy, and was made successively to appear and disappear by its 
alternate use and disuse. 

Sodium Biborate. Gowers 3 reports the occurrence, especially on 
the arms, but also over the trunk and legs, of an eruption resembling 
psoriasis, after the ingestion of the biborate of sodium. Some of the 
resulting patches were one and a half inches in diameter. Three cases 
in all are collated. In two the eruption faded when a solution of 
arsenic was added to the sodium salt. 

Stramonium. Deschamps (cited by Duhring) reports an erythema¬ 
tous rash after the administration of the thorn-apple. 

Strychnin. Skinner (cited by Van Harlingen) reports a case 
where an eruption of six weeks’ duration ensued upon the adminis¬ 
tration of quinin and strychnin together; the former in the dose of 1J 
grains (0.10), the latter in the dose of A of a grain (0.0025). 

Tanacetum. A case of varioliform eruption produced by the 
ingestion of drachms (6.) of the oil of tansy, administered for 
abortifacient purposes, is reported by Potter. 4 There were antecedent 
clonic convulsions. The result was not fatal. 

Tar and Turpentine. Erythematous, vesicular, and papular 
rashes are reported as resulting from the ingestion of these substances. 

The following medicaments may be added to the list of drugs 
capable, when administered by the mouth, of producing rashes: 

Anacardium, alcohol, bitter almonds, antimony, argenti nitras, ben¬ 
zol, chinolin, bitter-sweet, capsicum, cantharides, chloroform (after 
administration for anaesthetic purposes), duboisin, ergot, iodid of iron, 
guarana, kava-kava, creosote, resin, castor-oil, ipecacuanha, hyoscya- 

1 British Medical Journal, February 18,1871. 

2 Maryland Medical Journal, June 15, 1881, p.:91. 3 Lancet, September 24,1881. 

4 New England Medical Journal, October 15,1881. 


INF LAMM A TIONS. 


195 


mus, matico, lead and its compounds, sulphur and the calcium sulphide, 
veratrum viride, cocain, coninm, pimpiuella, rhubarb, sulphonal, 
tuberculin, and valerian. 

Many of these drugs have been effective in but few instances. There 
is no reason why the list should not be in the future greatly enlarged, 
as it is probable that every medicament is capable of producing a 
temporary efflorescence when the system is suffering from a special 
sensitiveness to its action. 

The diagnosis of the various medicinal rashes described above does 
not, fortunately, demand a recognition of the essential peculiarities 
impressed upon each by the exciting cause, since in many cases such 
peculiarities do not exist. The same drug may, on the one hand, pro¬ 
duce a rash differing widely in different individuals under different 
conditions, while, on the other hand, the urticarise resulting from the 
ingestion of “ head-cheese/’ quinin, and chloral may absolutely be 
indistinguishable. But to establish the fact that a medicamentous 
eruption is present in any given case is a long step in the direction of 
reaching the precise cause that has been in that case effective. This 
fact must often be obtained from the lips of the patient. The me¬ 
dicinal rashes are in general remarkable for their sudden appearance, 
their symmetry, their diffusion over large areas of integument, the 
presence of pruritus, the absence of fever, and their existence alike 
upon exposed and protected surfaces of the skin, thus hinting at the 
action of some cause not operating externally. Excluding syphilis 
and the exanthematous fevers, a generalized rash of sudden occurrence 
should always raise the suspicion of a dermatitis medicamentosa. 
Similarly in cases of pre-existing cutaneous disease, syphilis, eczema, 
or psoriasis, the sudden occurrence of lesions of a new type widely 
diffused, or of rapid aggravation in situ , or of speedy extension as to 
the area of those already in existence, should awaken the suspicion, 
if there be fever, of the exanthemata, and, without a febrile process, 
of the medicinal rashes. Thus, the author has seen two patients with 
eczema exhibit rapid rise in body-temperature, and subsequently develop 
a generalized variolous rash; and it is a matter of common experience 
to examine patients on the eve of a macular syphiloderm, or even long 
past the eruptive stage of that disease, showing their faces, necks, and 
shoulders covered with an acneiform rash produced by the potassium 
iodid. The practitioner cannot too strongly be urged to view with 
exceeding watchfulness the skin of any patient affected with any of 
the common disorders (eczema, acne, and psoriasis) when the eruption 
in any instance becomes anomalous as to type, distribution, or symp¬ 
toms. An illustrative example came under the author’s observation. 
A physician (on a trip from Colorado to Chicago) with a long-standing 
eczema of the scrotum and thigh, suddenly exhibited tumefaction of 
both hands with small, egg-sized, discrete, dull-red plaques, over the 
palms and dorsa; and in the centre of nearly all these lesions there 
developed a firm, whitish, elevated wheal, accompanied by severe burn¬ 
ing, tingling, and pricking sensations. He had been swallowing “ bro- 
midia,” a proprietary preparation containing bromid of potassium, 


196 


DISEASES OF THE SKIN. 


hydrate of chloral, and cannabis indica, each single drug being capable 
of inducing an exanthem, yet he had not the slightest suspicion of the 
real nature of his symptoms, having been questioned by a brother 
physician, to whom he exhibited his hands, as to the possibility of 
syphilis. 

The medicamentous rashes, as a rule, disappear rapidly after the 
withdrawal of the exciting cause, and they require no further manage¬ 
ment. In some cases the soothing lotions, baths, and dusting-powders 
employed in the treatment of acute eczema may be required. 

It should not be forgotten that the patient who exhibits these lesions 
is usually one who has been suffering from the real or fancied disease 
for relief of which the drug was taken, and that condition may require 
recognition and management. 

In Morrow’s excellent treatise it is clearly shown that the same 
drug may produce a variety of eruptive phenomena, and that the 
same eruptive features may result from the ingestion of different drugs. 
He points to what he concludes to be the neurotic origin of many of 
these rashes, and believes that the proof is inconclusive that they are, 
to any considerable degree, brought about by elimination, through the 
cutaneous glands, of the noxious element introduced with the drug. 
Tilden, however, calls attention to the fact that many of these eruptive 
phenomena are of the nature of angio-neuroses, similar to Trousseau’s 
“ tache cSrebrale ,” requiring often increase in the irritability of the 

cutaneous vessels, with exudation of 
serum, outwandering of cells, and, 
in case of hemorrhagic lesions, some 
change in the vascular walls them¬ 
selves. 

Feigned Eruptions are usually 
varieties of dermatitis (erythema¬ 
tous, bullous, traumatic), discolora¬ 
tions, or ulcers produced by acids, 
caustics, and other chemical agents, 
or friction, for the purpose of excit¬ 
ing sympathy, extorting charity, 
securing hospital comforts, transpor¬ 
tation to city life, etc. The persons 
employing these devices are, as a 
rule, criminals, hysterical young wo¬ 
men, mendicants, soldiers, sailors, or 
servants seeking release from ser¬ 
vice. The peculiarities, briefly, of 
these artificial eruptions are: their 
odd appearance, not resembling the 
well-known types of ordinary dis¬ 
ease; their sharp definition, due to 
the limitation of the disease to the 
area of contact of the article employed in its production; their oc¬ 
currence on parts most accessible to the hands and the eyes of the 


Fig. 43. 



Feigned eruption. 
(From a photograph.) 




INF LAMM A TIONS. 


197 


supposed victim of the disease, being in right-handed persons most 
perceptible on the anterior portions of the body, particularly over the 
face of the right thigh or leg, and over the left arm or shoulder; evi¬ 
dences of drops where a caustic liquid has been spilled over the surface, 
or of angularity in outline, due, as a rule, to downward flow of a fluid 
from above; and staining of the fingers, or nails, or the tissue beneath 
the latter, by the operator. In a suspected case the diagnosis may be 
made clear by covering the affected areas with a plaster or other fixed 
dressing, since the artificial eruption quickly gets well when the patient 
is prevented from making the effective applications. 

Many cases of dermatitis gangrenosa and erythema gangrenosa have 
proved to have been produced artificially by the patients themselves. 
Other diseases have thus been imitated. Among them may be named: 
sycosis, favus, alopecia, ringworm, scabies, bromidrosis, hematidrosis, 
chromidrosis, erysipelas, abscess, and syphilis. 

“ Chronic Pustular Dermatitis with Extension in Periph¬ 
eral Patches” has been described and figured by Hallopeau. 1 The 
trunk and the thighs were extensively covered with large deep brown 
plaques, having definite borders, and exhibiting here and there over 
the integument indurated projections of the size of a small coin. 
The elementary lesion was a vesico-pustule with a red areola, which 
spread centrifugally by multiplication and which eventually became 
covered with a crust. 


[D] Dermatitis Gangrenosa. 

(Sphaceloderma.) 

Gangrene of the skin may result from a dermatitis originally due to 
the action of either excessive cold or heat; to the action of externally 
applied chemical agents (caustics, strong acids, alkalies, etc.); to shock; 
to ergot and other substances ingested; to infectious diseases (lepra, 
tuberculosis, syphilis, erysipelas); to central nervous disease (decubitus, 
Raynaud’s disease); to disorders of the blood-vessels (embolism, throm¬ 
bosis, acute and chronic endarteritis obliterans, calcareous changes in 
the arterial vascular tunics); or to compression by ligature, or by 
tumors. 

Spontaneous Gangrene of the Skin occurs chiefly in hysterical 
female subjects, the affected plaques being irregular in outline and super¬ 
ficial or deep. After the slough has separated the plaques usually 
cicatrize without serious mischief resulting. Occasionally they spread 
in serpiginous directions over the surface. Though doubt has been 
cast on these cases, in consequence of the discovery among them of 
feigned disease, it is certain that the malady occurs as described, with¬ 
out the operation of external agencies. These cases are included in 
those described elsewhere as “ Erythema gangrenosum.” In making 
a diagnosis the feigned eruptions and their distinctive features should 
be kept in mind. 


1 Int. Journal of Rare Skin Diseases, 1890, iii. 1. 


198 


DISEASES OF THE SKIN. 


Dermatitis Gangrenosa Infantum (Multiple Disseminated 
Gangrene of the Skin in Infants; Varicella Gangrenosa; Pemphigus 
Gangrenosus; Bupia Escharotica; Gangrenous Infantile Ecthyma). 
As a consequence of the exanthemata (variola, varicella, rubeola, pur¬ 
pura, erythema nodosum), the head, shoulders, and trunk of some 
children exhibit crust-covered lesions which ulcerate and finally throw 
off* a gangrenous, split-pea- to small coin-sized, deep or shallow slough, 
after which repair commonly occurs. Severe losses are produced by a 
species of coalescence of smaller ulcers. 

These gangrenous points may occur beneath some previously exist¬ 
ing lesion or crust, or they may at the outset be spontaneous. In 
most cases there forms a vesicular lesion with rosy areola, that 
speedily bursts, leaving a blackish slough about which a circle of 
eliminating inflammation spreads. Thromboses result in the blood¬ 
vessels of the neighboring parts, oedema follows, and there is ex¬ 
cited a train of reactive symptoms—fever, vomiting, diarrhea, albu¬ 
minuria, cardiac or pulmonary troubles. The patient becomes greatly 
emaciated. Crocker reports hemorrhagic vesicles and bullae in grave 
cases. 

Brocq is careful to distinguish between these grave forms of disease 
and those to which should be denied the appellation dermatitis gan¬ 
grenosa. In these milder forms vesicular lesions may develop, simu¬ 
lating those of varicella, occurring perhaps in crops and accompanied 
by a mild fever. Some among them may be covered with a blackish 
crust, may indurate at the base, surround themselves with an angry 
zone of inflammation, and, especially about the trunk, the thighs, and 
the ano-genital region, ulcerate beneath the crust. Even though these 
ulcers coalesce and acquire a grave aspect, the result, as a rule, is not 
unfavorable. 

ktiology and Pathology. The subjects of this affection are infants 
and young children, from three months to several years of age. Beside 
the exanthemata which may precede, cases are on record as following 
tuberculosis, rickets, and syphilis. The process is one which, origi¬ 
nally dependent upon the toxic effects of specific cocci, evidently 
requires a special soil for its effective operation. 

The treatment should include support of the general system, with 
local antisepsis by the aid of boric-acid solutions, aristol, iodol, and 
the dressing of the parts which slough by the usual deodorizing agents. 

The prognosis is at times grave. 

Multiple Gangrene in Adults. Under this title Crocker 
describes two cases, one a male the other a female patient, in whom, 
as a consequence of scarlatina, or some poorly defined antecedent 
disorder, crops of pustules, followed by gangrenous sloughing, occurred 
in almost all parts of the body, one attack rapidly following another 
with rise of body-temperature. 

Spontaneous Gangrene of the Eyelids (Hilbert). A pustulo- 
crustaceous lesion of the upper lids with gangrene resulting in a 
small circular ulcer, is reported as occurring in two healthy children. 


INF LAMM A TIONS. 


199 


Symmetrical Gangrene of the Extremities (Local As¬ 
phyxia, Raynaud’s Disease). This affection is usually first an¬ 
nounced by the common signs of arrest of circulation in the capil¬ 
laries, numbness, loss of sensibility, and color of passive congestion 
(local asphyxia, digiti mortui ) in fingers and toes exposed to extremes 
of cold or of heat. The face, nose, ears, brows, and other regions and 
organs, may also be involved. Eventually subjective sensations are 
awakened, stinging and lancinating pains, pricking and crawling 
sensations. The parts involved, often The second and third pha¬ 
langes of the digits, first become livid, then cold, firm, and black; 
and gangrene of more or less of the affected tissue results, usually 
presenting the dry aspect. Bullae may form along the line of de¬ 
marcation. Separation of the gangrenous portions usually takes 
place slowly. The entire process may require but a few days or 
several weeks for its completion. 

Variations occur in a singular thinning of the digits, which may 
become indurated and slender; or they may be covered with small 
whitish cicatrices where a superficial slough has been separated; or the 
parts may become cool, white, like alabaster, and recover their tone 
without loss of tissue; the nails alone may fall; or indeed the entire 
process may meet with arrest in the early stage of blueness and asphyx¬ 
iation of the extremities. The mild forms which terminate in recovery 
may recur, and the type may become each time more severe until 
finally gangrene results. 

Etiology and Pathology. This disease occurs equally in the two 
sexes and at all ages, and often in the cold weather of the winter 
season. There is a growing suspicion that many cases are of syph¬ 
ilitic origin, as the disease has followed specific infection. It has also 
succeeded tuberculosis, diphtheria, the exanthemata, diabetes, and 
hemoglobinuria. It is without question due to either centric or periph¬ 
eral nerve-excitation, and is immediately produced by venous stasis. 

Treatment is by employment of the galvanic current, stimulation (as 
in dermatitis with congelation), and friction with stimulating alcoholic, 
camphorated, or oleaginous lotions. It is desirable to apply both 
electricity and (in some cases) dry cupping over the spinal region. 

The prognosis is in some cases grave; when the morbid condition is 
limited to a small part of the body, recovery is often satisfactory. 


Erysipelas. 

(Gr. epvOpdg, red ; tt eX2.a, the skin.) 

(St. Anthony’s Fire. Ger., Rothlauf, Erysipel; 

Fr ., Erysipele, La Rose.) 

Erysipelas is an acute and specific inflammation of the skin and subcutaneous tissue, 
characterized by diffuse, shining redness, pain, swelling, and elevated temperature 
of the affected part, terminating in desquamation, and usually accompanied by 
fever, due to the presence of the streptococcus erysipelatis. 

Symptoms. This disease is usually preceded by a prodromic period 
of malaise (lasting for twenty-four hours or less), which may be ushered 


200 


DISEASES OF THE SKIN. 


in by one or several chills followed by febrile symptoms. The latter 
are accompanied by anorexia and often by vomiting, with general 
depression and headache. 

The eruptive symptoms are generally first displayed at a given 
point, from which the disease progresses. It is commonly first noticed 
in a nut- or egg-sized patch, the integument of which is tumid, slightly 
elevated, irregular in contour, distinctly circumscribed, and presents 
a rosy or crimson-reddish color with a peculiarly smooth and charac¬ 
teristic shining or glazed appearance. The sensations awakened may 
be those of moderate pruritus, of pain, heat, or burning. To the touch 
the affected part is tender, moderately firm, and perceptibly hotter than 
normal. The color fades under pressure to a yellowish-white. 

In typical cases the erysipelatous blush and swelling spread over 
an area which may be of the size of that of the palm, or may even 
cover the surface of an entire limb or a region of the body. In cases 
of moderate grade the inflammation attains a maximum of extent 
and severity within a week, remains apparently unaltered for a day or 
more, and then begins to abate, with amelioration of all the concomit¬ 
ant symptoms. The fever which often precedes the eruption, continues 
unabated during its progress, the temperature rising to 105° or 106° 
F., with nocturnal exacerbation, cephalic and lumbar pain, dryness 
of the tongue, gastric distress, and occasional delirium. As involution 
of the disorder is accomplished, the redness is replaced by the brownish, 
bluish-red, and dirty-white shades often seen after the disappearance 
of erythema multiforme, the epidermis finally desquamating in vari¬ 
ous degrees according to the extent of the preceding inflammation. 

In other cases, where the exudation of serum beneath the epidermis 
has been rapid, the epidermis is raised in the form of vesicles, pus¬ 
tules, or bullae, more often the latter, and, precisely as in the severe 
forms of dermatitis calorica, with which erysipelas presents a certain 
analogy, gangrene of the skin may result in the part affected. Gan¬ 
grene is particularly apt to follow the disorder when it attacks the seat 
of surgical wounds and injuries. 

Erysipelas Ambulans is a term used to describe that form of the 
affection in which the erysipelatous blush, after involving a given 
area, spreads with greater or lesser rapidity to the parts in the vicinage, 
either by direct extension and uniform advancement in one direction of 
the tumid and distinctly circumscribed border, or by linear, digital, or 
irregular prolongations radiating from the inflammatory focus. As 
the blush and swelling advance in one direction, there is usually a 
correspondingly rapid disappearance on the other. At other times, 
the disease, while extending to a new area and abandoning the old, is 
relighted in the latter, and thus an irregularly involved and irregularly 
extending erysipelatous surface presents for weeks the varying phe¬ 
nomena of the disease. In yet other cases, chiefly those in which there 
has been a history of traumatism, a long erysipelatous linear streak 
or band may spread from the site of the traumatism in one direction 
or another, suggesting the indurated lines observed in lymphangitis. 
In severe cases, the febrile, nervous, and other symptoms are grave, 


INFLAMMA TIONS. 


201 


including coma, delirium, meningitis, and the signs of serious involve¬ 
ment of the lungs, pericardium, pleura, and bowels. Metastatic 
abscesses may also occur in the cutaneous and subcutaneous tissues, 
the joints, the peritoneal cavity, and even in the viscera. Death may 
result from these complications, or from shock, exhaustion, or pyemia. 

Surgical accidents aside, the face is the commonest seat of the disease, 
where it may be first seen upon one side of the nose, one cheek, the 
lip, or the eyelid. It often attacks the lobe of the ear after the opera¬ 
tion of piercing the lobule for the insertion of ear-rings in women; 
thence it may extend over the whole face, inclusive of the mucous 
linings of the mouth and the nose, that present a dry, tumid, and 
glazed appearance, suggestive of the symptoms displayed upon the skin. 
The inflammation may extend to the hairy parts, but in many cases it 
exhibits a species of reluctance to transgress the limits there presented. 
It may be noticed in cases of mild grade, where no applications have 
been made to arrest a local progress, that the elevated border spreads 
symmetrically to within a few lines of the male beard or the hairs at 
the edge of the forehead, and there spontaneously rests. In severer 
grades these limits are readily surpassed, and then, as a rule, the 
extension is rapid and formidable. In this way the entire head may 
become enormously swollen, suggesting to a casual observer that it is 
fully twice its normal size. The patient then is greatly disfigured ; his 
scarlet lips are swollen and parted, permitting the escape of saliva; 
the ears, as usual when greatly enlarged, project in a marked degree 
from the side of the head j the eyelids are oedematous and incapable 
of separation ; the face is disfigured by bullae or crusts; and the 
mind disordered by violence of the fever or the accesses of delirium. 
When recovery ensues the hairs are apt to fall. 

All other regions of the body may be invaded, such as the vaccinated 
arm, the leg whose skin is involved in venous varicosities, the scrotum 
or the umbilicus of the infant, the genitalia of the newly delivered 
woman, the breast of the nursing-mother, and every surface which 
has been the seat of punctured, incised, contused, or poisoned wounds, 
or other accidents of the integument to which the germs of the dis¬ 
ease may have had access. 

Habitually recurrent and Chronic forms of Erysipelas, whose 
identity with the disease here described it is difficult to establish, have 
been noted by several authors. The diagnostician is sufficiently often 
consulted in cases where an erythematous eczema of the face, an acne 
rosacea, a symptomatic erythema, or an acute inflammatory oedema is 
described by a patient as chronic or recurrent “ erysipelas.” The 
lesions to which such terms are restricted by careful writers, however, 
are often forms of chronic dermatitis, such, for example, as occasionally 
follow dermatitis calorica. Instances occur in which the face, wholly or 
in part, is the seat of a low grade of inflammation with local heat, 
swelling, redness, considerable infiltration, and some tenderness, the 
skin being irritable and worse after exposure to a high wind or after 
excesses at the table. But most of such cases fail to exhibit the 


202 


DISEASES OF THE SKIN. 


distinct imprint of erysipelas; they are not only chronic in course, but 
are exceedingly indolent, often lasting for years; they are unaccom¬ 
panied by fever; they are distinctly limited in all accesses of aggrava¬ 
tion to the same part of the face; they are never characterized by a 
bullous efflorescence; many occur in the subjects of chronic alcoholism; 
and the specific germs of erysipelas are not present. 

The febrile symptoms are, throughout, persistent and characteristic 
of a specific toxemia. The body-temperature, as has been seen, may 
reach 105° to 107° F., with vespertine exacerbations and remissions; 
it may also become subnormal. If not relieved in the course of seven 
or eight days, complications may be expected, namely, oedema, abscess, 
phlegmonous inflammation, gangrene, or inflammatory accidents in¬ 
volving the membranes of the brain, lungs, heart, bowels, kidneys, 
peritoneum, or joints. 

Etiology. Erysipelas is caused by the streptococci of Fehleisen, 
which gain admission to the tissues through some lesion of the surface. 
The site of infection may be a surgical or other wound, or it may be 
a slight scratch, or an unrecognized abrasion of the skin or mucous 
membrane. 

In the face, catarrhal and ulcerative processes involving the mucous 
membrane of the mouth, ears, and nose, are often the cause of erysip¬ 
elas, these processes occurring in a wide range of disorders from syph¬ 
ilis of the nasal bones to caries of the teeth. Tuberculous and other 
ulcers, as well as eczema and several skin diseases, frequently furnish a 
means of ingress to the streptococci. Injuries of, and surgical opera¬ 
tions upon, the scalp not conducted with antiseptic precautions, and the 
common piercing of the lobe of the ear in women and female children 
for the insertion of ear-rings, may be followed by the appearance of 
the disease upon the scalp, as a result of which the hair often falls. 
Fistules, vaccination, lesions of the tender umbilicus of the newborn 
infant, aud railroad accidents may be named as common causes of the 
disease in other regions. 

Predisposing causes of this disease are to be sought for in cachexia, 
general debility, alcoholism, kidney disease, epidemic influences, trau¬ 
matism, violation of hygienic rules, and, occasionally, the recurrence 
of previous attacks. Beside these causes, it is alleged that constitu¬ 
tional predisposition and particular articles of diet (mussels) may be 
responsible for the disease. 

Since the malady is invariably the result of infection due to the 
presence of a streptococcus, the essential cause lies in the specific germ, 
in the absence of which none of the predisposing causes named can be 
effective. It is clear, however, that the predisposing causes suggested 
are those in which the multiplication of such germs and their entrance 
to the general economy are most facilitated. 

Pathological Anatomy. Under the microscope, the skin and subcu¬ 
taneous tissues are seen to be infiltrated, the exudate being more serous 
and less rich in protoplasm than that observed in ordinary phlegmonous 
inflammation of the skin. The bullae represent rapid exudation of 


INF LAMM A TIONS. 


203 


this same serosity to the congested epidermis, and the elevation of the 
latter in consequence. The elements of the rete and connective tissue 
are for the same reason swollen, the lymphatic and blood-vessels are 
enlarged, and the cutaneous follicles are engorged, the root-sheaths of 
the hairs being occasionally separated, thus necessitating temporary loss 
of the pilary growth. In proportion to the severity of the exudative 
process pus-corpuscles may appear, and represent, for the most part, 
degenerative changes in the subcutaneous tissues resulting in abscess. 
The phenomena are, in short, those of superficial or of deep-spreading 
dermatitis. After death, the skin which has been the seat of the dis¬ 
ease cannot be distinguished microscopically from that of another part 
of the body. 

Diagnosis. Erysipelas is to be distinguished from the erythemata, 
from dermatitis of various grades, from eczema, and from scarlatina. 
As a rule, its recognition from all is readily effected, when the presence 
of the fever in erysipelas is kept in view, as also the peculiar shining, 
swollen, and rosy-reddish to damask hue of the affected parts. The 
redness is never produced, as in scarlatina, by multiplicity of reddish 
puncta, nor is it so widely diffused as in that disease. Erysipelas may 
at times be accompanied by a pruritic sensation, but the patch which it 
affects is never by any possibility scratched. By this simple test alone 
one may often distinguish an erysipelas of the face from an eczema of 
the same region in a child. From a chronic dermatitis with thickening 
of the affected tissues and redness of the surface, erysipelas is to be 
distinguished by its teudency to spread, by its acute career, by its 
frequent association with bullous or vesicular lesions, and by the 
color, outline, and raised border of the affected patch. However, it 
must be understood that to these localized patches of chronic der¬ 
matitis several authors have given the name “ chronic erysipelas/ 7 the 
difference between the views held on this point being chiefly one of 
terms. 

Treatment. The method of treating erysipelas by the administration 
of the tincture of iron internally has long been popularized among 
American practitioners. This preparation is given in full doses, from 
10 to 50 drops, day and night every two to three hours, irrespective 
of the febrile state. 

The constitutional treatment is important, but is solely symptomatic, 
and should be directed to lowering the temperature, to obtaining proper 
functional activity of all the organs of the body, and, in prolonged 
cases, to sustaining the strength of the patient. Locally, when the 
erysipelatous blush has a distinctly circumscribed outline, an annular 
zone extending for an inch or more in width upon the sound and affected 
skin may be either covered with the tincture of iodin, or be pencilled 
with a crayon of nitrate of silver, or be painted with a saturated solu¬ 
tion of the same salt. The purpose of such treatment is to limit the 
extension of the disease. It is true that these measures will not always 
succeed, but it is erroneous to assert with some authors that they always 
fail. Certain it is that, whether effective or not in the production of 
the result, the advancing border of the disease will often fail to surpass 
the limits thus artificially described. Collodion has been employed for 


204 


DISEASES OF THE SKIN. 


a similar purpose, and Darlin 1 advocated the revival of this method 
of treating the disorder, basing its claim on the fact that the dressing 
diminishes the temperature of the part thus protected, and that, by the 
compression excited, it interferes with septic absorption. Heppel 2 
recommends the painting over the surface of a 10 per cent, solution of 
carbolic acid in alcohol, as an abortive treatment, for which Braithwaite 3 
substitutes a similar solution of tannin. 

Excellent results are occasionally reached in the local treatment of 
erysipelas, first, by attempting to limit the extension of the disease by 
the application of the tincture of iodin over the peripheral zone, and, sec¬ 
ondly, by retaining over the entire surface affected neatly applied com¬ 
presses saturated with a solution of the hyposulphite of sodium in the 
strength of about 1 drachm (4.) to the ounce (32.). Spencer, of the 
United States Army, has frequently seen this disorder upon the face 
entirely relieved by this treatment in forty-eight hours. 

With many judicious practitioners all attempts to limit the extension 
of the disease by local applications of an irritating sort (corrosive sub¬ 
limate, nitrate of silver, carbolic acid, tar, turpentine, etc.) are con¬ 
demned as positively injurious. Dry heat applied by the aid of cotton 
or wool, cold compresses, or iced lead-lotions with intermissions of appli¬ 
cation, salicylic acid, boric acid, iodol, or iodoform in powder may be 
used. Resorcin in solution has been followed in some cases by excellent 
results. Ninety-five per cent, alcohol or a saturated solution of boric 
acid often give good results if painted frequently over and for an inch 
or more beyond the affected area, or if applied on compresses. 

Koch applies one part of creolin, four of iodoform, and ten of lan¬ 
olin, covered with gutta-percha. Nussbaum uses ichthyol and collo¬ 
dion, or equal parts of ichthyol and vaselin covered with a 10 per 
cent, salicylic lint. Hallopeau uses one part to twenty of the sodic 
salicylate upon folds of linen. Elliott and others strongly recommend 
ichthyol in lotions, in oils, or in ointments. It may be used in strength 
varying from 10 to 25 per cent., and is kept constantly applied to the 
affected area and for some distance beyond it. 

Erysipelas rarely attacks a patient in vigorous health. The large 
majority of all the subjects of the disease are either those who have 
previously suffered from manifest general ill-health, or who have been 
complaining of local ailments, trifling wounds, nasal catarrh, or surgical 
accidents. It is these precedent conditions which often demand the 
special attention of the physician or the surgeon. 

It is needless to add that all surgical indications are to be fully met 
when they are present; pus is to be evacuated, crusts removed, and 
drainage secured. The physician and surgeon alike should never forget 
that the disease is infectious, that the patient is to be isolated and to 
be supplied with an abundance of pure air, and that fomites, surgical 
instruments, and even the non-disinfected hands of attendants are 
capable of transmitting the disease. 

Finally, there are forms of erysipelas which are remediless; they 
are usually septic in character. The scarlet blush spreading from an 

1 Bull. gen. de Ther., 1881, vol. ii. p. 239. 

8 British Medical Journal, April, 1881. 


2 Arch, of Derm., April, 1881. 


INFLAMMA TIONS. 


205 


irreparable injury of long duration is often the last protest of Nature 
against the damage which even her final resort of gangrene will not 
avail to repair. 

Prognosis. Under favorable circumstances erysipelas, even of 
severe grade and extensive invasion, terminates in complete resolution. 
Reserve should be made, however, in every case, as a serious compli¬ 
cation has often transformed the simplest into the gravest form of the 
disease. The very young, the cachectic, the victims of drink, the 
aged, the inmates of hospital wards depressed by other illness, and 
those mentally distressed by destitution and neglect, are particularly 
liable to suffer from grave and fatal forms of the malady. 

The patients who fill the beds in most lying-in hospitals are young 
women, either unmarried or deserted by their husbands, and unpro¬ 
vided with the necessities of life by those upon whom such a respon¬ 
sibility rests. The mental depression thus originating in connection 
with the septicemic influences, too common in all large charities, is 
responsible for much of the relation which erysipelas often seems to 
sustain to the puerperal state, as also for the appalling mortality which 
it may exhibit under these circumstances. 


Erysipeloid. 

(Erysipelas Chronicum, Progressive Phlegmon, Erythema 

Migrans.) 

This term is employed by Rosenbach 1 to designate a special inflam¬ 
mation of the integument occurring as a complication chiefly of trau¬ 
matisms. When a wound is infected with the special poison of the 
disease, a peripherally spreading tumid and empurpled halo encircles 
the site of infection, which slowly disappears in the part originally at¬ 
tacked while it extends progressively to another area. The advancing 
border of the disease is distinctly circumscribed and may also be 
festooned or scalloped. New points may appear from which the viola¬ 
ceous redness may spread, while others are in a state of apparent 
inactivity. This affection may be complicated with furunculosis, but 
scaling is said never to occur. Itching and burning sensations are 
usually present. 

Rosenbach believes that the source of this disease is a micro-organism 
of the order of Cladothrix, existing in putrid flesh and cheese, from 
pure cultures of which organism he is reported to have produced the 
disease. His position, however, is yet unfortified by ample experiments 
of other observers. 

The disease affects chiefly the ringers and hand (according to Elliott, 
also the scratched toes) of scullions, meat-dressers, fish-dealers, poultry- 
cleaners, and persons of similar occupation. The distinction between 
this disorder and erysipelas is based chiefly on the indolence of the 
former, its more superficial involvement of the skin, and the entire 

i Verk. d. Deutsch. Cong. f. Chirurg., 1887. 


206 


DISEASES OF THE SKIN. 


absence of constitutional symptoms. It is to be carefully distinguished 
from Crocker’s “ dermatitis repens ” (some instances of which may be 
here included), from erythema multiforme and erythema iris, and from 
ringworm of the hands. 

Treatment is efficient when there is local application of formalin, 
ichthyol, resorcin, pyoktanin blue, pyrogallol, potassic permanganate, 
or the mercurials in salves or in lotions. 


Pellagra. 

(Lat. pelliS ) the skin; ceger , diseased.) 

(Lombardy Erysipelas, Lombardy Leprosy, Risipola 
Lombarda, La Rosa, Mal Roxo.) 

This disease has attracted attention by its extensive ravages in Lom¬ 
bardy and the contiguous provinces, including a portion of Southern 
France and Spain. It is a constitutional epidemic disorder, accom¬ 
panied by an exanthem, which justifies its brief consideration in this 
connection. 

The first symptoms of the disease, usually first noted in the spring, 
are prodromic and characterized by marked fatigue, malaise, and occa¬ 
sionally by febrile symptoms. Soon the face, neck, chest, backs of 
the hands, and forearms (when exposed to the sun) are affected with 
an erythema of a dull, lurid hue, disappearing on pressure, which may 
be accompanied by desquamation, occurring in successive years chiefly 
in the summer season, often fading in the autumn, at times with des¬ 
quamation. After frequent relapses the skin becomes of a dark 
olive-brown, bluish-red, or deeply pigmented and bronzed hue, and 
general exfoliation of the epidermis follows in large flakes. Simulta¬ 
neously, an extraordinary degree of muscular feebleness is noticed; 
the skin becomes pruritic or hyper^esthetic; and a sensation of chilli¬ 
ness is induced, similar to that observed in general exfoliative derma¬ 
titis. As in that disease also, the fingers gradually become semi-flexed 
into the palm, and gastro-intestinal derangements supervene, accom¬ 
panied by a furred tongue, inappetence, colicky pains, and diarrhea. 
Disorders of the nervous system are betrayed by melancholia, disturbed 
vision, idiocy, convulsions, and symptoms of meningitis. Post mortem, 
pachymeningitis, with induration, atrophy, and other secondary changes 
of the brain and cord have been observed. 

The more one studies the cutaneous symptoms of pellagra, the more 
it is apparent that the erythema displayed is one corresponding in all 
points, save localization, to that of the other symptomatic erythemata. 
Its colors are in different hues according to the age and sex of the 
patient and the stage of the disease. It disappears under pressure at 
first; later it may persist even before the pigmented condition is pro¬ 
duced; it may be of congestive type and accompanied by bullous 
efflorescence and crusting with erosive features. It may subside in a 
fortnight not to return, or return with successive seasons till the integu- 


INFLAMMATIONS. 207 

ment becomes gradually wrinkled, thinned, and in the xerodermatous 
state of impoverished senility. 

After the eruptive symptoms, the important features are the mus¬ 
cular feebleness, the remarkable tendency to chills alternating with 
febrile accesses, the flexion, more or less persistent, of the fingers 
into the palms, and, in fatal eases, changes in the nervous centres such 
as pachymeningitis and sclerosis of nerve-tissue, producing during the 
life of the patient paralytic and paretic symptoms, melaucholia, im¬ 
becility, and dementia. 

Pellagra has been very generally believed to originate in the use, as 
an article of diet, of maize which was either invaded by the fungus of 
ergot, or had developed other deleterious substances after its reduction 
to a coarse powder. While this cannot be said to have been fully dis¬ 
proved, it is certain that individuals have suffered from the disease who 
have never partaken of maize, and also those who have not been spe¬ 
cially exposed to the action of the sun, which in some cases seems to 
have served a^ the exciting cause of the disorder. The exact etiology 
of the malady should rather be traced by the statesman and politico- 
economist. The wretchedness, poverty, poor food, and hopeless moral 
and social condition of the inhabitants of the pellagrous districts, many 
of them toiling under a burning sun, half-starved, emaciated, and 
despairing, should explain largely the symptoms of the scourge which 
afflicts them. Certainly there is here to be found a very satisfactory 
explanation of the failure of several writers on the subject to describe 
a disease of such typical aspect and career as to command recognition 
of its distinct and special identity. 

Authors have indeed sought to distinguish between pellagra and 
pseudo-pellagra by establishing a difference of cause only, but this is 
futile. In cachectic men and women who have never been exposed to 
the sun and have not been known to be poisoned by eating decom¬ 
posed or fermented maize, all the symptoms of pellagra have been 
noted; and in others mere exposure to the rays of the sun has in the 
cachectic and in those suffering from visceral disease (gastric carcinoma, 
disease of the suprarenal capsules, etc.) produced characteristic lesions 
of pellagra. 

The treatment is by prophylaxis; improvement of the hygienic and 
climatic conditions of the patient; quinin and tonics in cases of de¬ 
bility; proper management of the nervous and gastric troubles; and, 
when practicable, a generous dietary. Lombroso recommends, as a 
prophylactic measure, care in the storing of the grain. 

The prognosis is favorable in some cases, which may be so mild as 
to be scarcely noticeable. In others it is grave; and in districts 
where the disease prevails extensively the mortality has been frightful. 

Ackodynia (Epidemic Erythema) is an affection suggesting in 
its symptoms those of pellagra. It first occurred in,Paris, in the year 
1828, in an infirmary for aged men; and has been since recognized in 
epidemic form in France, Belgium, Algiers, Mexico, and a few other 
countries. 

The disease begins with facial oedema, gastric distress, conjunctival 


208 


DISEASES OF THE SKIN. 


injection, and hyperesthetic symptoms, with a sense of formication 
and pricking in the parts chiefly affected. The cutaneous lesions are 
erythematous, displayed in points over the extremities, and especially 
over the hands and the feet, particularly their palmar and plantar 
surfaces. It has either a simple or polymorphic expression, and is 
concluded by a furfuraceous or lamellated desquamation. When fluid- 
containing lesions are produced, these are either vesicular or bullous, 
and filled with limpid or reddish contents. When the consequent 
exfoliation occurs over the palmar and plantar surfaces there may be 
a desquamation similar to that occurring in some of the exfoliating 
dermatoses, large horny flakes and casts being either firmly adherent 
to, or separable from, the tissues beneath. 

The grave complications of the cases are: oedema followed by atro¬ 
phy, paretic symptoms, febrile and gastric complications, and senile 
marasmus. 

One of the most characteristic features of the disorder is the blackish 
hue of the skin of affected persons over the breasts, belly, flanks, chest, 
axillae, and inguinal regions. 

The pathology is obscure; the treatment, that indicated by the gen¬ 
eral ill-health of the patients; and the prognosis, unfavorable. 


COCCOGKENOUS AND BACILLOGENOUS DERMATOSES. 

A group of disorders differing among themselves is now recognized 
as being essentially due to the invasion of the skin or its follicles with 
pathogenic cocci and bacilli. The dermatoses next to be considered 
are not occasioned solely by such organisms, nor are all the cutaneous 
affections produced by such a cause here included. Their etiological 
relations, however, are of sufficient importance to justify the grouping 
of those next described. 


[A] Furunculus. 

(Lat. furunculus, a petty knave.) 

(Boils. Fr., Clou; Ger., Blutschware.) 

Furunculosis is a disease characterized by the occurrence of one or more circum¬ 
scribed, cutaneous or subcutaneous abscesses, called “furuncles,” which usually 
terminate by necrosis of tissue in the centre of the phlegmon, the expulsion of 
the necrotic mass in the form of pus or a core, and a resulting cicatrix. 

Symptoms. Furuncles commonly begin as both tender and painful 
indurations in the skin or its subjacent tissues, the summit of each of 
which soon becomes visible in the epidermis as a reddish punctum. 
A furuncle is the result of an active inflammatory process, limited to 
a definite area, and of greatest intensity at the centre of the involved 
mass. This centre is often represented by a hair-follicle, the pustule 
that forms subsequently being perforated by a hair. 

More or less rapidly thereafter these symptoms are succeeded by 


INF LAMM A TIONS. 


209 


increased redness, heat, and tumefaction, the latter producing a nut- 
or egg-sized tuberosity, well projected from the surface, or fairly im¬ 
bedded within or beneath the derma. A yellowish point in the centre 
of the erythematous swelling soon announces the occurrence of suppu¬ 
ration. When accidentally or artificially opened at this summit exit 
is given to a thick yellowish pus in which blood may be commingled 
from the traumatism of neighboring capillaries. The small abscess 
may then, after discharging its purulent contents for a few days, grad¬ 
ually close by granulation, or may also expel from its cavity a tenacious, 
pus-covered, yellowish-green slough, known as the “ core.” This evac¬ 
uation is usually followed by relief of the tense and throbbing pain 
which is the well-known subjective characteristic of the furuncle. 

The length of time requisite for the completion of this process varies 
with the extent of tissue involved, from a few days to several weeks. 
Boils may occur in any part of the body, but are most common about 
the face, the auricular region, the neck, the armpits, the ano-genital 
region, the hips, the buttocks, the breast, and the extremities. They 
may occur as single or as multiple lesions, or they may succeed each 
other in crops, especially about the buttocks, trunk, and thighs, for 
a period of several months. It is this succession of boils to which 
the term “ furunculosis ” is specially applied. The disease of the skin, 
in cases of furunculosis, may produce a constitutional effect manifested 
in pyrexia, which is usually encountered, when the furuncles are few 
and short-lived, only in individuals of irritable constitution. There 
is also a decided chloro-anemia due to the pain, fever, purulent drain, 
derangement of nervous centres, inappetence, and consequent perver¬ 
sion of nutrition. 

The sequels of boils are maculations of a violaceous tint, often per¬ 
ceptible in the skin for weeks and even months after their disappear¬ 
ance, and pin-head- to coin-sized cicatrices which are permanent. 

Etiology. The microbe producing boils is the staphylococcus pyog¬ 
enes aureus. The remote cause, however, is often exceedingly obscure. 
It is true that boils are encountered in typical subjects of diabetes, of 
the exanthemata, and of “hospitalism,” where anemia, asthenia, 
marasmus, malnutrition, and exhaustion resulting from excesses, from 
grave general disease, from low fevers, and from nervous strain, play 
a prominent part. But the reverse is also true. 

Scratching, eczema, scabies, and other cutaneous diseases, lice, and 
external irritants of various sorts are responsible for many boils, espe¬ 
cially those that are few and not followed by similar lesions. When, 
however, such sequence occurs, it should never be forgotten that the 
pus is autoinoculable, and that furuncles, if sufficiently numerous and 
large, are amply capable of disturbing the general economy. The 
collar-button at the back of the neck; the edges of an unyielding 
corset, for one unaccustomed to it; a hard bench; the saddle-tree; and 
many similar articles, may be the exciting cause of furuncles. 

Account should always be had, in cases of persistent furunculosis, 
of externally operating poisons. In this category must be included 
sewer-gas emanations, arsenical wall-papers, and the poisons handled 
in the trades, e. g., by dyers, lead-manufacturers, etc. 

14 


210 


DISEASES OF THE SKIN. 


Lastly, it is exceedingly common for patients thus affected to apply 
to practitioners for remedies intended to e< purify the blood; ” and, 
inasmuch as the iodid of potassium is often mischievously prescribed 
in response to this demand, the original trouble is thus enhanced to a 
manifold extent. Many cases of furunculosis are instances of boils 
resulting originally from external irritation, that have greatly multi¬ 
plied and finally profoundly affected the system under the impulse of 
the so-called <e blood-purifying” process. 

Pathology. Authors have attempted to explain the phenomena of 
furuncle by supposing the process to be due to inflammation attacking 
a sebaceous follicle in the derma, or a pilary follicle or sweat-gland 
beneath the skin, or the perifollicular tissues, or the connective-tissue 
pedicle which passes downward from the fundus of the hair-follicle to 
the subcutaneous tissue, or the blood and lymphatic vessels which 
surround the sac. It is reasonable to suppose that they all are right. 
No one of the component parts of the skin is known to be exempt 
from the changes induced by the inflammatory process. It is difficult 
to discover in the furuncular lesion any symptoms which set it apart 
from the other results of localized inflammation, its phenomena differ¬ 
ing from those of ecthyma, acne, pustular eczema, anthrax, etc., only 
by the seat and extent of the inflammation. The core of the furuncle 
represents a necrosis induced by the violence of the exudation, and so 
does the gangrenous slough which falls after a severe dermatitis calo- 
rica. The core of the furuncle is moist, yellowish, and puriform, 
because it is completely immeshed beneath the epidermis, and is pus- 
soaked. The core or slough of a gangrenous dermatitis may be as 
dry as a crust, from desiccation in consequence of exposure to air, or 
in various degrees be moistened by the fluids escaping from the tissues 
beneath. Where there is no core in furunculus this absence is due 
to the fact that the purulent products of the inflammation pass with 
readiness from the peripheral to the central parts of the phlegmon 
without having to leak through or between, or to be pressed against, 
masses of centrally disposed elements, whose vitality is thus the more 
readily lost. Inflammation of tissue in a practically closed chamber, 
under tense pressure, under slight pressure, exposed freely to, or in 
all grades protected from, the air, will always differ in its phenomena. 
It is wiser to attribute these differences to the circumstances under 
which the inflammation progresses than to any peculiarities in the 
nature of the process itself. 

The contagious character and parasitic origin of furuncles have been 
studied by a number of observers. Ging^ot, 1 Startin, Trastour, Low- 
enberg, Pick, Pasteur, and others have, with varying success, repro¬ 
duced these lesions by experimental inoculation. The name torula 
pyogenica has been given to a vegetable parasite recognized in furun¬ 
cular products, which parasite, however, in development, is to a marked 
degree modified by the nature of the site in which it is implanted. 

It is with these demonstrations in view that Gingeot suggests the 
employment, in the treatment of furunculosis, of parasiticides, the acid 

1 Bulletin gen de Therap., Jan., Feb., and March, 1885. 


INF LAMM A TIONS. 


211 


nitrate of mercury, iodin in tincture, carbolic acid, and borated alcohol. 
Internally are administered sulphur and the hyposulphite of . sodium 
in large dilution. 

Diagnosis. Boils are to be distinguished from carbuncles by the 
exaggerated symptoms of the latter. Circumscribed furuncular ab¬ 
scesses of the groins and the axillae are not to be confounded with 
suppurating, sympathetic, or virulent buboes of these regions, associ¬ 
ated with genital or extra-genital contagious, venereal sores. This 
caution seems unnecessary, but many such errors have been made. 
Furuncles of the anal and genital regions in point of diagnosis may be 
significant of surgical affections of the neighboring parts (perineal, 
peri-pros (atic, peri-urethral, and scrotal abscesses in men; suppuration 
of the vulvo-vaginal gland in women, etc.). 

Treatment. The debilitated constitution of many patients affected 
with boils indicates clearly the need of a tonic regimen, including the 
administration of iron, quin in, and strychnin, the mineral acids, and, 
contrary to the generally accepted opinion of the laity, a generous diet 
of milk, cream, eggs, and fresh meats. To these articles of diet 
wines and malt liquors may at times be added with advantage. Change 
of climate, of diet, of cooks, and of the habits of life is most service¬ 
able in cases of prolonged furunculosis. The mineral waters, at some 
of our health-resorts, prove especially valuable for the debility which 
often results from these disorders. The urine should always be exam¬ 
ined for sugar, albumin, and an excess of urates. The internal reme¬ 
dies which possess reputation in this complaint are arsenic, sulphur, 
and the sodic sulphites, the alkalies, tar, fresh yeast in tablespoonful 
doses, phosphorus, and the syrup of the hypophosphites of lime, iron, 
soda, and potassa. 

The sulphide of calcium, which was once more highly esteemed 
by the larger number of practitioners than any other of the internal 
remedies named, is given in doses of ^ to ^ of a grain (0.0133-0.0066) 
every three or four hours in the day. It is extremely doubtful whether 
the drug exerts any influence whatever upon furuncles. In lithemia 
the acetate or the citrate of potassium is given in large dilution or the 
liquor potassse; in gouty states, colchicum and the alkalies, including 
the sodic salicylate. No one of these articles, however, may be de¬ 
scribed as an efficient and certain remedy for the complaint; many 
cases will progress without hindrance from any or all of them. 

Attempts in the direction of aborting a furuncle by the topical appli¬ 
cation of the stronger alkalies (aqua ammonise) or acids, caustics or 
cautery, ice, or premature complete incision with the scalpel occasion¬ 
ally succeed, but more often they fail. 

The best methods of local treatment are the simplest. The part 
may be frequently bathed in a hot, saturated solution of boric acid, 
and immediately after be covered with lint thickly spread with a paste 
formed of 2 drachms (8.0) each of zinc oxid and powdered starch to 
the J ounce (16.0) of vaselin ; or with a freshly made benzoinated zinc 
ointment. When the pain is unusually intense the parts may be covered 
with hot borated lotions covered with protective. When the pus is 
evacuated and the slough wholly or in part detached the dressings for 


212 


DISEASES OF THE SKIN. 


most cases, after washing with the hot borated lotion, are : boric acid 
in powder, iodol, iodoform (objectionable on account of its odor), 
aristol, or hydronaphtol one part to one hundred of fuller’s earth. 

Violent squeezing of a furuncle to separate its slough or to evacuate 
its contents should never be practised. 

Prognosis. Eventually the worst cases are relieved when unaccom¬ 
panied by systemic or visceral disorders, and when the circumstances 
of the sufferer permit him to pursue the most advantageous course 
(travel, diet, abstraction from business, etc.). The resulting cicatrices 
depend upon the severity of the process. Often they are small, and 
in the course of years are scarcely distinguishable; in exceptional cases 
they are large, persistent, and disfiguring. 

[B] Anthrax. 

(Gr. avOpai f, a live coal.) 

Anthrax is a term which has been applied, not without some confusion in the past, 
to two affections here separately considered. 

1. Anthrax Simplex (Carbunculus, Carbuncle. Ger., Carbunkel; 
Fr., Carboncle.) Anthrax simplex is a circumscribed, cutaneous, 
and subcutaneous abscess, usually larger than a furuncle, that is due 
to the presence of staphylococci, and is characterized by dense indura¬ 
tion and sloughing, terminating, in favorable cases, by the production 
of a persistent cicatrix. 

Symptoms. Carbuncles are often preceded by malaise, chill, and 
pyrexia of severe grades. There is commonly a burning pain at the 
site of the lesion. In cases where the anthrax is formidable and seated 
upon or near the head alarming symptoms of prostration, stupor, 
somnolence, and even coma, may be noted. With and without these 
concomitants, a dense, dull-red, indurated, and painful phlegmon soon 
appears, varying in size from that of a small hen’s-egg to that of an 
orange, and even much larger, involving not only the skin, but also 
the tissues beneath. Suppuration finally occurs, but the pus is not 
confined to a single space; it undermines the integument, and often, 
through several apertures, leaks out indolently to the free surface. 
The fenestrated or cribriform appearance of the skin covering the car¬ 
buncle constitutes, in this stage, one of its most striking features. 
Through these apertures may be distinguished the whitish or yellowish 
pus-soaked sloughs, or portions of a single slough, which can at times 
be extracted through the orifice. Often the entire mass separates in 
a single slough involving the skin and subcutaneous tissues, leaving 
a crateriform ulcer of formidable size, which, in favorable cases, pro¬ 
ceeds to heal by granulation. The resulting cicatrix is at first of a 
deep violaceous tint, and later becomes blanched, it is indelible. 

The fever which usually accompanies this process may be mild or be 
severe, or, more commonly in dangerous cases, be of a typhoid char¬ 
acter. It results unquestionably from sepsis due to unliberated pus 
and necrotic tissue, and is naturally most grave in its consequences 
where patients are weakened by previous asthenic disorders. Under 


INFLAMMA TIONS. 


213 


these unfavorable circumstances the carbuncle may spread at the pe¬ 
riphery, with islands of necrotic tissue and ill-conditioned pus separated 
by bridges of empurpled, infiltrated, and yielding skin. 
biThe peculiar lesions of this disease most often appear upon the back 
of the neck, the back of the trunk, and the lateral aspect of the hips 
and thighs, usually in a single development, though occasionally two 
or even three carbuncles of small or of medium size may coexist. 
The reason for their appearance in the localities named is clear. It is 
here that the skin is most thick and resisting, and, as a consequence, 
purulent foci when formed are covered in by the most voluminous 
layers of the connective tissue of the corium. 


Fig. 44. 



Vertical section of anthrax. Dense network of fibrous bundles, with interspaces communicating 
and extending to the subcutaneous tissue. (After Warren.) 


Fig. 45. 
I 



f p flip 

Section of anthrax. Infiltrated papillse are seen at l, distended in balloon-shaped figures, 
between which the rete is compressed ; at p and mp column® adiposse are seen; /, division of 
elements, the fibrous bundles resolving into protoplasm. (After Warren.) 

Etiology. Anthrax simplex is produced by the obscure causes to 
which reference has already been made as probably effective in the 
production of boils. The two may coexist, or the one may follow the 
other, and there may occur intermediate forms which might be assigned 
to either class. The disease is encountered more often in men than in 
women, and in later than in earlier life, simply because the tissues 
constituting its sites of preference offer in these individuals and at 
these ages a greater resistance to the exit of pus. The pus-cocci may 




214 


DISEASES OF THE SKIN. 


sustain an etiological or purely an accidental relation to the lesion. 
Carbuncle is at times an epiphenomenon in cachexia, diabetes, albu¬ 
minuria, syphilis, pemphigus, and exfoliative dermatitis. 

Pathology. The pathological anatomy of carbuncle is well described 
by Warren, 1 whose observations conclusively show that the inflamma¬ 
tory process here is one with that seen in the simplest pustule. The 
peculiar symptoms of carbuncle are due solely to the formation of the 
phlegmon beneath the dense and extremely thick masses of fibrous 
tissue found in the back “ for the protection of that comparatively 
defenceless portion of the body.” The elements, multiplying with 
intensity of the inflammatory process, first in the subcutaneous adipose 
tissue, pass upward along the fat-columns, described by Warren as 
“ columns adiposte, 77 crowd in these and push along the horizontal 
clefts branching from either side, infiltrate the derma, pass along the 
edges of the hair-follicles, fill the papillae until the latter “ balloon 77 
with pus, .ooze to the surface through the cribriform apertures in the 
undermined epidermis, and soak the bundles of fibrous tissue, rela¬ 
tively intact, that constitute the undetached mass of sloughing tissue. 

The general symptoms in anthrax (pyemic, septicemic, or sympa¬ 
thetic) are due solely to pus-imprisonment. The pus-formation is due 
to the presence of the staphylococcus pyogenes aureus and the toxin 
it produces. Back of all lies the favorable soil (in the diabetic, the 
cachectic, etc.) for multiplication of these micro-organisms. 

Diagnosis. It follows from what has preceded that carbuncle and 
furuncle differ solely in the depth of the starting-point of the phleg¬ 
mon, and the density and resisting power of overlying tissue. The 
carbuncle is, therefore, flatter, denser, less rapidly developed, larger, 
less tender, and more painful; opens by many rather than by one or 
two apertures; and is followed by larger sloughs, ulcers, and cicatrices, 
and occasionally by fatal results. 

Treatment. Crucial and other deep incisions in the local treatment 
of carbuncle are certainly inferior in results to the method advocated 
by Wood 2 and Talor, 3 whose method is employed in cases with com¬ 
plete success, namely: A saturated solution of pure carbolic acid is 
injected with a hypodermatic syringe through the several apertures in 
every direction into the sloughing tissues. When the orifices are not 
sufficiently numerous, the point of the needle is thrust through the 
thinned integument at the summit of the swelling at several points. 
The pain is severe, but short-lived; the tissues are blanched, indurated, 
and destroyed; the slough in a few days is readily separated after 
division of its slender fibrous attachments; and the ulcer rapidly con¬ 
tracts with the sequel of a smaller scar. It is necessary to use pure 
acid in saturated solution to prevent absorption of the injected fluid 
and the resulting toxic effects. 

Relief is afforded in many cases by hot borated lotions and fomen¬ 
tations, with the requisite skill in the surgical dressiug of the parts by 
carbolated lotions, extraction of the slough wholly or in portions by 

1 The Pathology of Carbuncle, or Anthrax. Cambridge, 1881, p. 15. 

2 Toledo Medical and Surgical Journal, December, 1880. 

3 Australian Medical Gazette, December 1, 1881. 


INFLAMMA TIONS. 


215 


the forceps, and the subsequent employment of boric acid, iodol, iodo¬ 
form, or aristol, or the paste recommended in the treatment of furun¬ 
cles. An excellent method of withdrawing the purulent aud sloughing 
contents of the carbuncle is to apply over it at the proper period an 
exhausted receiver, such as a common cupping-glass. 

Erasion of the entire abscess with the curette and subsequent anti¬ 
septic dressing is the best radical measure of relief. 

In many cases the antiseptic treatment of a carbuncle furnishes 
decidedly the best results as regards the comfort of the patient and 
limitation of the disease. By this treatment there is absolutely no 
surgical interference with the lesion, beyond the incisions made for the 
evacuation of pus. Violent squeezing and manipulation of the car¬ 
buncle are interdicted; it is freely powdered with boric acid, iodol, or 
iodoform, and on it is laid soft, felt cloth, thickly spread with any 
emollient and antiseptic salve. Bulkley 1 advises the use of the ordi¬ 
nary zinc salve for this purpose. Boric acid in powder, or iodol, 
thickly dusted over the carbuncle and covered with antiseptic wool 
will also be found a useful dressing. 

Internally calx sulphurata may be administered In full doses; it has, 
however, a very questionable effect in diminishing the pus-formation. 

Other constitutional treatment is that demanded in the case of furun¬ 
culosis, including the liberal employment of tonics, a generous diet, a 
strict observance of the rules of hygiene, and stimulants when indi¬ 
cated. Pyrexic, septicemic, pyemic, and adynamic states require the 
special management of such complications, including cold sponging of 
the body-surface in fever, and the use of quinin, the mineral acids, 
and stimulants, with artificially applied heat in the algid condition. 
The urine should always be examined for sugar and albumin. 

Prognosis. A serious issue need only be anticipated when the com¬ 
plications described above are grave in character, or they occur in 
asthenic constitutions. 

2. Anthrax Maligna (Malignant Pustule. Fr., Pustule maligne, 
Charbon). Anthrax maligna is a carbuncular lesion resulting from 
infection of the skin or other organ of the body, with a virus contain¬ 
ing the anthrax-bacillus, furnished by some animal infected with 
splenic fever. 

This disease in man, fortunately rare of occurrence, is usually derived 
from some animal affected with the specific malady variously termed 
“ anthrax,” “ charbon,” “splenic fever,” “splenic apoplexy,” or 
“ Texas fever.” The lesion under consideration is also termed 
1 6 splenic fever carbuncle. ” After inoculation with the disease from 
an infected animal the human subject may (a) perish from systemic 
poisoning wholly septicemic in character with few external symptoms; 
or (6), when life is sufficiently prolonged, may suffer from visceral 
symptoms, and develop subcutaneous tumors; or (c) may exhibit the 
symptoms of the disease now under consideration. 

In from twelve to eighteen hours after inoculation a painless macule 


1 Journal of the American Medical Association, May 16,1885. 


216 


DISEASES OF THE SKIN. 


is first manifested, usually upon the dorsum or other parts of the hands 
or the face to which the virus has had access. This macule is followed 
by an inflammatory and pruritic papule, which is rapidly transformed 
into a flaccid vesicle filled with a bloody serum and surmounting a firm 
indurated u nucleus ,” or by a larger blood-filled bleb reposing upon a 
somewhat painful, engorged, and often densely indurated base involv¬ 
ing extensively the subcutaneous tissue. One or more similar lesions 
may follow in the surrounding integument, coalescence of which lesions 
produces a large, angry, oedematous, and often gangrenous ulcer. The 
involved skin may be of the size of that of a small coin, or be as large 
as the palm of the hand. The lymphatic vessels and ganglia enlarge, 
and often suppurate; metastatic abscesses form ; and the constitutional 
symptoms supervening are those described in connection with Equinia. 
If recovery is to ensue, the gangrenous mass will slough as in 
favorable cases of carbuncle; if the result is to be fatal, the process is 


rapidly aggravated by oedematous infiltration extending to a wider area 


and by larger quantities of tissue falling into necrosis. 

In some cases the accompanying fever is high, with marked delirium ; 
in other cases, it is of a typhoid character. Death results from shock, 
septicemia, or exhaustion, though in cases where the lesion is circum¬ 
scribed and unattended by constitutional symptoms recovery may ensue. 1 


Etiology. This disease is induced by infection from one of the lower 


animals, usually horned cattle, that suffer from charbon or splenic 
fever, and are handled by herders, ranchmen, etc. The susceptibility 


of the carnivora to the disease is very much less 
than that of the herbivora. It is claimed that 
not only direct inoculation may produce the dis¬ 
ease, but that it may be extended also by the 
medium of flies and other insects. More re¬ 
cently it is asserted that food, drink, and even 
inspired air may be the medium by which the 
disease is conveyed. 


Fig. 46. 


J 



Pathology. Since the first investigations re¬ 
ported in 1864 by Davaine to the French 


Malignant pustule bacilli Academy, Pasteur, Klebs, Koch, Carnevin, and 


IlguaiH puotuic UttUlill 1 11 1* 

and pus-corpuscles. others have rally demonstrated that splenic fever 


(About x 3oo.) is solely due to the multiplication in the blood 
and tissues of a rod-shaped bacillus, the bacillus 


anthracis, which is always motionless. Under culture the bacilli may 
develop long filaments, many times larger than the original rods, with 
a distinct sheath about a protoplasmic cylinder, which filaments after 
segmentation furnish oval and shining spores. These spores have 
been cultivated again and again, with resulting germs that have 
produced the disease artificially in the lower animals. 

The pathological anatomy of malignant pustule is that of carbuncle 
with the added fact that specific bacilli and spores are abundantly 
present in the blood and debris of tissue. 



INF LAMM A TIONS. 


217 


Diagnosis. In establishing a diagnosis care must be taken to avoid 
one source of error. Malignant pustule in man is not of frequent 
occurrence in America, but occasionally various cutaneous eruptions are 
produced upon the hands after contact with animals or their hides upon 
which chemical solutions have been applied for the destruction of lice. 
These solutions usually contain arsenic, corrosive sublimate, or other sub¬ 
stances capable of exciting a localized dermatitis. Chancre of the face, 
severe anthrax simplex (carbuncle), and poisoned wounds,are all differ¬ 
entiated by their relatively indolent course and the absence of gangrene. 

The treatment is to be conducted on the principles of general thera¬ 
peutics. Popper, 1 a Hungarian physician with a large experience in 
malignant pustule, reports success by deep incision of the lesion, extend¬ 
ing the operation to the subcutaneous connective tissue. This measure 
has always proved successful when practised before the occurrence of 
the general symptoms. 

A number of other authors have had successful results after excision. 
Pitts, 2 for example, reports two successful excisions of malignant 
pustules in the case of brothers. Johnson, of New York, and Robin¬ 
son, of England, each reported, in 1892, successful results after excision. 
Hebra was not in favor of the early cauterization of the malignant 
pustule, and it may be considered a questionable method of procedure. 
A grave case of pustule is recorded, 3 in which recovery ensued after 
the hypodermatic injection of the tincture of iodin. Three syringefuls 
of the pure tincture were deposited beneath the skin at the periphery 
of the diseased surface, and lint soaked in the same fluid was applied 
over the slough. Internally, 14 drops of the tincture (1.), with 3 grains 
(0.26) of the iodid of potassium, were also administered. Normal 
cicatrization followed in this and six other cases recorded. 

Crucial incisions with the free application afterward of pure carbolic 
acid have been followed by good results. Baker, of London, reports 
rapid and complete relief after excision and the free use of iodoform. 
Internally, the hyposulphite of sodium and quinin are successfully 
employed. The febrile, typhoid, and adynamic features of the disease 
are to be treated in accordance with the recognized principles of general 
medicine. 

Prognosis. The disease proves fatal in about one-third of all cases. 
Early excision in a healthy subject gives promise of satisfactory results. 

[C] Equinia. 

(Lat. equus, a horse.) 

(Glanders, Farcy. Fr., Morve, Farcin; Ger., Rotzkrank- 

HEIT, MALIASMUS.) 

Equinia is a contagious, virulent, and inoculable disease, transmitted to man from 

the horse, mule, or ass, and produced by a bacillus resembling that of tuberculosis* 

Symptoms. The acute form of this disease commonly follows a 
period of malaise lasting a few hours or a few weeks, in which period 


i Centralb. f. Chir., 1881, No. 33. 

3 Arch. gen. de Med., February, 1883. 


2 Brit. Med. Journ., March 19,1887. 


218 


DISEASES OF THE SKIN. 


the patient complains of vague pains of a rheumatoid type, followed 
by thermal variations. The body-temperature rises rapidly to a point 
of danger, with chills, fever, diarrhea (often following constipation), 
and rapid exhaustion, the picture being nearly that of acute septicemia. 

The cutaneous symptoms begin often with an erysipelatoid blush, 
the surface, affected and swollen, also producing papules, vesicles, 
pustules, and bullse, with dense but ill-defined induration of the sub¬ 
cutaneous tissue; or reddish and yellowish papules appear, which, as 
in the case of the fluid-containing lesions, coalesce and furnish a bloody 
discharge. A more or less rapidly occurring sloughing ensues, some¬ 
times with extensive gangrene, though the patient often succumbs 
before the culmination of the morbid process. The lymphatic vessels 
are swollen and well-defined, often indurated. These symptoms chiefly 
affect the face, hands, feet, and other exposed parts of the body. There 
is often a sanious or purulent and offensive catarrh from the nostrils, 
the mouth, and the eyes, the inflammatory process spreading rapidly to 
the deeper mucous surfaces. This catarrh, chiefly nasal in site and 
declared conspicuously by the nasal voice due to the blocking up of 
the nose by the viscid, foul-smelling, hemorrhagic discharge, is one 
of the most characteristic features of the malady, and is of impor¬ 
tance in the diagnosis. 

In the chronic form of the disease this nasal catarrh is less conspic¬ 
uous at the outset, though later it may be a prominent feature of the 
malady. A few days or weeks after infection, pustules, as in the acute 
form, resembling those of variola but flattened and never umbilicated, 
begin as vesicles or even as papules, coalesce to bullae, occur in succes¬ 
sive crops, and run on to the production of multiple abscesses, poorly 
defined on the extremities and about the face; much more rarely on 
the trunk. These abscesses may be of phlegmonous type, or be deep, 
brawny infiltrations with purulent foci, extending over months of 
invasion and decline of the disease. From these abscesses, pea- to 
nut-sized over the face, larger on the limbs, flows an abundant, sanious, 
semi-liquid, or viscid, yellowish, and offensive pus. Ulcers form at 
many points, with purplish borders, oval or roundish contour, and 
thin edges, suggesting the appearance of the scrofulous ulcer of classical 
type. The edges may be softish or indurated. By their multiplication 
or coalescence the lips, nose, lids, and other parts of the face may in 
part or wholly be destroyed. The disease may steadily advance, or 
may seem to be arrested for a time and reawaken to activity. Mean¬ 
time the lymphatic glands are either unchanged or are enlarged by 
sympathy. In the course of months or years there is a fatal issue. 
The disease is, fortunately, rare. 

Etiology and Pathology. Equinia is almost invariably produced by 
infection from horses, a history of contact with such animals being one 
of the important points in establishing a diagnosis. The infection is 
produced by the glanders-bacillus (Weichselbaum, Schiitz, Loeffler, 
Bouchard). This bacillus is nearly of the size of tubercle-bacillus , 
being cultivated and capable of producing the disease in the lower ani¬ 
mals after injection of cultures. The bacilli are found in the greatest 
abundance in papules, abscesses, blood, and brain-tissues of the diseased. 


INFLAMMATIONS. 


219 


The treatment is that of the septic condition, and is of little avail. 

The prognosis is in the highest degree grave. 

Pustules from Cadaveric Infection. In a number of lesions 
recognized especially upon the fingers and hands of those in contact 
with the bodies of the dead, tubercle-bacilli have been recognized. Such 
lesions are the “verruca necrogenica,” described in the chapter on 
Tuberculosis Cutis. Other lesions, however, generally known as 
“ dissection-wounds,” occur with symptoms of acute poisoning, upon 
the hands of those exposed to the danger of post-mortem examinations 
and dissections. At the inoculation-point, which may be either the 
site of a former abrasion, a rent, or the mouth of an open follicle, a 
painful vesico-pustule, papule, tubercle, wart, furuncle or hemorrhagic 
bulla rapidly rises from an angry and indurated base, with hyperemic 
areola in dull-red shade. Suppuration, crusting, or ulceration, limited 
to the seat of the lesion, may follow; or there may occur lymphangitis 
in various grades with consequent pyemic or septicemic involvement 
of the system. Suppurative and Don-suppurative axillary buboes are 
common. Gangrene and necrosis of the soft parts and the bones, espe¬ 
cially the phalanges, may ensue, as also a fatal result from the systemic 
disorders named. In a few cases a chronic marasmus is induced. 
Prophylaxis, by proper protection of the hands, and the immediate 
cleansing and disinfection of any accidentally wounded point, is of the 
highest importance. The treatment is to be conducted in accordance 
with the principles already described. 

There is reason to believe that accidents of this kind may be pro¬ 
duced by absorption of the alkaloids engendered in the cadaver by the 
decomposition of proteid substances, called “ ptomaines.” The 
ptomaines were first isolated and named by the late Professor Selmi, 
of Bologna, subsequent investigation seeming to prove that in chemical 
constitution they do not differ from the alkaloids produced by albu¬ 
minous decomposition in vegetables. Brieger identified neuridin, 
cadaverin, putrescin, and saprin in the dead body, and with these 
a peculiarly toxic alkaloid to which he has given the name <c myda- 
lein.” All these substances are capable, after ingestion or admission 
by other avenues to the circulation, of inducing salivation, vomiting, 
diarrhea, dyspnea, paralysis, and death. The lethal issue in the case 
of lesions of the character here designated, is probably due to the fact 
that, at the site of the pustule of irritation or traumatism, one or 
more of these toxic alkaloids has gained admission to the lymphatic 
circulation. 

Pustules and other Lesions resulting from Wounds in¬ 
flicted by Reptiles and Insects are often of an insignificant 
character. Such are the trivial results of the bites or the stings of 
flies, fleas, mosquitoes, ants, bees, hornets, etc. At other times, how¬ 
ever, serious and even fatal consequences have been recorded. The 
wounds produced by the tarantula and the scorpion (which frequently 
lurk in the clusters of tropical fruit now imported to almost every part 
of the United States), as also of venomous reptiles, may prove to be 


220 


DISEASES OF THE SKIN. 


grave. Urticarial, vesicular, pustular, papular, bullous, and petechial 
lesions may thus originate and be the cause of a more or less severe 
dermatitis with toxic symptoms. In the latter event it is common in 
America to administer as remedial agents alcoholic stimulants as freely 
as they can be ingested. 


[D] Delhi Boil. 

(Aleppo Evil, Biskra Bouton, Oriental Boil, Gafsa 
Button, Natal Sore. Fr., Clou de Biskra.) 

This is a chronic endemic disorder characterized by the occurrence 
of painful nodosities upon the face, the hands, and other portions of 
the body. The lesions are one or multiple pea- to bean-sized papules, 
which subsequently become purulent and ulcerate indolently, or which 
become covered with scales. They are often grouped in patches and 
followed by cicatrices. The exact nature of the malady thus variously 
named is unknown. It is quite fully described by Fox, Farquhar, 
Pollack, Willemin, and other authors, as occurring in India, the 
region about the Euphrates and Tigris rivers, and along the northern 
coast of Africa, especially Algeria and Morocco. The descriptions 
given suggest that, in some instances at least, several different disor¬ 
ders have been included under these titles, such as the lesions of lupus 
and syphilis, and the frequently formidable symptoms produced in the 
skin by the vegetable parasites in tropical countries. 

Laveran 1 has described the Biskra bouton as occurring not only 
in Biskra but also in the adjoining oasis. It shows itself as an 
endemic only in the months of September and October, and continues 
until December, no new cases appearing in January and February. 
All ages, both sexes, the strong and weak, are liable to the disorder. 
The eruption affects the face and the extremities by preference, some¬ 
times also the trunk. It ordinarily attacks the same person but once, 
yet may recur. So long as the disease prevails, the least excoriation 
has a tendency to become Biskra bouton. At first there is a reddish, 
painless, elevation of the skin, the size of a pin’s head, that grows 
slowly, so that at the end of four or five months it attains the size of 
a small furuncle; the centre of this elevation dries and a brownish 
crust forms, which is easily removable. Beneath this crust there 
usually forms a small round ulcer. The papules may occur in patches, 
bearing thick crusts which long persist. The crusts are remarkably 
dry, and if undisturbed may eventually fall and leave no scar, though 
frequently ulceration progresses beneath the crusts. 

The ulcers are usually single, but they may be multiple, and may 
coalesce to form large ulcerating, granulating patches, They are 
usually irregular in form, with hard borders, and soft red floors cov¬ 
ered more or less with fungoid granulations and a thin ichorous dis¬ 
charge. Lymphangitis, erysipelas, and phlebitis, occur as complications. 


1 Annal. de Derm, et de Syph., 1881, t. i. p. 173. 


INFLAMMA TIONS. 


221 


There are no peculiarities in the crusts. Epidermic cells, pus-corpus¬ 
cles, and bacteria are commonly recognized by the microscope. 

Treatment is not very successful, and often an expectant treatment is 
the best. In the majority of cases the ulcers should be treated on 
surgical principles, with antiseptic and bactericidal dressings. Iodo¬ 
form, tincture of iodin, nitrate of silver in stick or in solution, and 
various preparations of the mercurials have been used with success. 
In limited cases caustics, the cautery, or even surgical extirpation may 
properly be employed. As regards its pathogenesis, Weber’s view 
is accepted that the disease is contagious and inoculable, and per¬ 
haps auto-inoculable. The virus exists in the crusts, but its nature 
is not established. Carter’s opinion as to its parasitic nature is not 
tenable. 

Altounyan, of Turkey, 1 protests against the view entertained by 
Geber and others, that the Aleppo button is a term applied indefinitely 
to various cutaneous disorders. In his view it is a specific disease 
beginning, independently of the hair-follicles, as a small acneform 
papule, pinkish in color and disappearing on pressure. Afterward it 
grows deeper, larger, and harder, and becomes more adherent and 
more vascular. Still it is livid, sensitive, smooth, and boggy to the 
touch. Pus forms centrally and dries into grayish-brown crusts which 
are rupioid in character. Beneath is a spongy ulcer, with ragged 
margin, ovoid contour, and ichorous discharge. Healing is followed 
by the production of a permanent and deforming scar, the entire course 
of the disease lasting one year. 

Elliott, of New York, who made a microscopical examination of 
some specimens furnished him by Altounyan, reports that the disease 
was limited to the epidermis and corium, and that its area was occu¬ 
pied by small round inflammatory or formative cells and epithelial 
elements. There was a distinct line of separation between the healthy 
and the diseased tissue. No cryptogamous or other micro-organisms 
were recognized. The hair-follicles and other glandular structures 
were intact. 

Altounyan found the best treatment to be the painting of the button 
with the tincture of iodin, and that, as a rule, one attack furnished 
immunity against a second. He believes the disease to result from the 
bite or the sting of an insect. 

Phagedena Tropica (Aden Ulcer, Malabar Ulcer). Hirsch, 
Parke, and others describe a condition of disease peculiar to travellers 
in tropical countries, rare in temperate zones, those particularly being 
attacked who have been exhausted by fatigue, malaria, and malnutri¬ 
tion. In these cases a slight traumatism becomes later the seat of a 
vesicle or a bleb from which as a centre spreads a rapidly phagedenic 
sore extending by sloughs through skin, muscle, tendon, and bone. 
The disorder is usually first noticed on the exposed parts of the lower 
limbs, but other regions may earliest be involved. In mild cases there 
is arrest of the process before severe destruction is accomplished, and 
then cicatrization follows. 


< Journal of Cutan. and Ven. Diseases, June, 1885, viii. No. 6. 


222 


DISEASES OF THE SKIN. 


This disease occurs chiefly among the natives of the tropics, but it 
also attacks travellers. It is aggravated by all unfavorable climatic 
and individual conditions. Microbes, supposed to be pathogenic, have 
been discovered by Boinet, who also cultivated these organisms and 
produced successful inoculations of animals. 

The treatment is precisely that employed for all similar surgical emer¬ 
gencies, viz., support by proper food and medicines; locally, antisepsis 
and parasiticides. The caustics employed by the French are inferior 
to effective parasiticides, such as borated, salicylated, and sublimate 
dressings. 


[E] Phlegmona Diffusa. 

(Gr. foeyfiovfj, an inflamed tumor.) 

Phlegmona diffusa is a grave form of non-circumscribed cutaneous inflammation in 
which the integument becomes livid, hot, swollen, painful, and apt for necrosis, 
this process occurring in one or many places to a considerable depth, accompanied 
by fever and systemic disturbance. 

The word phlegmon is employed by most English and Americau 
writers to indicate a circumscribed cutaneous inflammation which ter¬ 
minates naturally in suppuration, and which, as to the tissues involved, 
is larger than an ecthymatous pustule, yet is not large enough to be 
termed an abscess. Circumscribed phlegmons are represented by most 
furuncles, and, at one stage certainly of their career, also by carbuncles. 
In the disorder under consideration, however, the symptoms, both local 
and general, are far more serious than either furuncle or carbuncle. 
The first evidence of trouble may be a severe chill, followed by high 
fever and a deep-seated hammering pain, felt in the part which is the 
seat of the disease. This site is soon recognized as an oedematous area, 
of dull red or livid hue, tensely infiltrated, of the familiar brawny 
type and indeterminate outline. All these symptoms, which rapidly 
increase as resolution is very rarely attained, are followed by suppura¬ 
tion at one or more points. In diffuse phlegmon, however, the brawny 
tenseness of the inflamed skin has been so great that, as a consequence, 
vascular thrombosis occurs and the circulation is greatly impeded be¬ 
tween the points where pus forms or about a single point. The tissues 
then become more or less necrotic, both during and after the formation 
and evacuation of pus. 

The fever meantime may abate or may entirely remit or, in grave 
cases, may steadily persist. In the latter event the subcutaneous tissue, 
fascia, periosteum, bones, joints, and ligaments may be involved. But 
in all favorable cases the systemic condition is greatly improved when 
pus is no longer deeply or extensively formed, and when the gangre¬ 
nous shreds and sloughs are well loosened or are entirely removed. 

The u Acute purulent oedema” of English authors and the Gangrene 
foudroyante of the French may be regarded as severe types of diffuse 
phlegmon. In most of these severe cases patients die septicemic 
before complete evolution of the cutaneous inflammation has been 
reached. In other cases, the affected part, suddenly losing its tense, 


INFLAMMA TIONS. 


223 


brawny hardness, becomes emphysematous, or crepitates with bubbles 
of gas produced by decomposition. The patient may then become 
somnolent or delirious, or be the victim of an intercurrent and fatal 
involvement of the kidneys, lungs, liver, spleen, or bowels. 

The treatment of diffuse phlegmon is largely surgical, and in this 
day is simple. Incision, drainage, and disinfection are the three 
essential requirements. These measures thoroughly assured, the sys¬ 
temic treatment is by quinin, stimulants when indicated, and the 
accepted remedies for the typhoid condition generally, including rest 
in the recumbent posture and a proper supply of wholesome air and 
food. Amputation of limbs may be necessitated to save life. 

The prognosis rests almost entirely upon the extent, diffusion, and 
severity of the local inflammation, and the systemic condition of the 
patient. In a previously healthy subject, with good hygienic environ¬ 
ment and the absence of thrombosis, pyemia, septicemia, and erysipelas, 
the results will generally be favorable. With the reverse of these 
conditions the outcome may be serious as regards the loss of a limb, 
deformity, or a fatal issue. 


[F] Sycosis. 

(Gr. gvkov , a fig.) 

(“Non-par asitic” Sycosis, Sycosis Vulgaris, Mentagra, 
Ficosis, Folliculitis Barbie. Ger., Bartfinne.) 

Sycosis is an acute or a chronic inflammatory affection of the body-surfaces provided 
with relatively long hairs, the follicles and the peri-follicular tissues of which are 
involved in an exudative process, producing papules, pustules, tubercles, infiltrated 
patches, and crusts perforated by hairs. 

The title “ sycosis” no longer indicates an idiopathic affection. It 
is employed in these pages to designate a group of different disorders, 
which, affecting, for the most part, the region of the male beard, may 
be for practical purposes classified as follows: 

(A) Coccogenous Sycosis. In this class are to be studied the most 
numerous of the cases to which the term “sycosis non-parasitica ” 
was once given, and which are all due to invasion of the pilo-sebaceous 
crypt by pus-cocci. These pyogenic organisms may be either primarily 
or secondarily effective in producing the symptoms of the disease. In 
many cases a suppurative folliculitis follows the disorders included in 
the group here last named. 

(B) Bacillogenous Sycosis. This disorder is described by Tom- 
masoli. 1 

(C) Hyphogenous Sycosis. (Barber’s Itch, Ringworm of the 
Beard.) This disorder is due to the presence of the trichophyton 


i Monatsch. f. prakt. Derm., 1883, p. 483. 


224 


DISEASES OF THE SKIN. 


(trichophytosis barbce). It is described in this work among the Tineae, 
and is rarer than the other forms here tabulated. 

(E) A group of Sycosiform disorders cau also be recognized which 
differ somewhat from those named abcve. They include the pseudo- 
sycoses, the eczemas limited to the region of the beard with acneiform 
features, the eczemas of the same region with seborrhoic complications, 
and the still rarer sycoses, possibly due to tuberculous infection of the 
pustular lesion of ordinary sycosis. 

The description which follows relates to the parasitic forms of sycosis 
not complicated by the presence of the trichophyton. 

Symptoms. The lesions appear upon the face, involving one or both 
cheeks successively or simultaneously, the chin, the upper lip, the eye¬ 
brows, the scalp, the axillae, and the pubes. The disease, however, 
is almost always limited to the region of the beard in men. In this 
respect sycosis differs from acne and other disorders of the sebaceous 
glands of the face with which authors have sought to identify it, since 
not only is it, as a rule, strictly limited to the region of the beard, but 
the non-hairy portions of the face of the patient are also free from 
comedones, acne-lesions, and other symptoms of a cutaneous disorder. 

When seated upon the upper lip the first symptoms may be those of 
a nasal catarrh; seated elsewhere an eczematous attack may precede the 
onset of the disease. It may be ushered in with the acute symptoms 
exhibited in the early stage of some forms of eczema, and with tume¬ 
faction accompanied by a sensation of heat and burning; but often a few 
isolated and indolent lesions, the presence of which scarcely awakens 
attention, are the first traces of the disorder. Soon there may be 
recognized a larger or smaller number of discrete, flattened or conical, 
reddish and painful papules, tubercles, or pustules, the anatomical seat 
of which is distinguished as the pilary follicle because of the penetra¬ 
tion of each lesion by a filament of hair. These lesions may persist, 
and when typically discrete and visible at the part where the hair makes 
its exit from the duct of the follicle they suggest the appearance of 
the surface of the fig, whence the disease derives its name. They 
are apt to occasion a burning and at times a decidedly pruritic sensation 
when, being picked or torn open by the fingers, the pus concretes into 
a crust at the base of the hair. In severer cases these lesions, while 
not coalescing, are so closely set together as to form a patch of contin¬ 
uous infiltration. These patches may be weeping or be crusted; in the 
latter case the crusts are apt to be small and numerous, each crust being 
limited to the shaft of a single hair, and leaving when removed a 
minute crateriform excavation at the mouth of the follicle. 

Involution of several lesions may be followed by fresh crops, and, 
sooner or later, distinct patches of disease are thus formed. When 
fully developed the surface of the skin is reddened, swollen, infiltrated, 
and thickened; covered irregularly with papules, pustules, crusts, and 
scales, and often with excoriations. The disease is apt to lapse into 
chronic conditions, usually the result of improper treatment, and in 
ancient cases the deformity is characteristic and totally unlike that 


INFL A MM A TIONS. 


225 


produced by the vegetable parasites. The hairs are usually fixed 
firmly in their follicles, but from those in which active suppuration is 
in progress the hairs may be plucked without occasioning much pain. 
In the cases which have been treated for years the hairs are thinned 
and decidedly lacking in vigor. 

In typical and neglected cases of long standing, in which the region 
of the beard is involved, an important clinical feature is the symmet¬ 
rical, general, and uniform involvement of the entire surface. The 
picture of one cheek is very nearly that of the other. The sparse 
hairs scarcely serve to disguise the reddened, tumid, painful surface 
beneath, which displays the several lesions of the malady. Furuncles, 
abscesses, cicatrices, vegetations, and eczema of the ears may compli¬ 
cate the process. Sycosis is occasionally acute in its course, but is 
more often chronic and rebellious. A typically chronic and untreated 
case of the malady rarely terminates by spontaneous involution. 

The thinning of the hairs, described above as a consequence of long 
persistence of the disease, is far more characteristic of it than any 
distinctly resulting alopecia; the latter, however, very rarely occurs, 
but is then remediless. The samp may be said of resulting cicatriza¬ 
tion, which is one of the very rarest consequences, and which is gen¬ 
erally due to bacillogenous infection. 

The absence of certain symptoms in this disorder is as significant as 
is the presence of others. Adenopathy of the cervical glands is very 
rare, but when present it should awaken suspicion of another malady. 
The disease when of longest persistence as to time, produces great 
unsightliness, but no deep-seated, subcutaneous, small- or large-nut- 
sized nodules or tubercles, forming the u lumps’’ so characteristic of 
trichophytosis of the beard. Sycosis vulgaris is a disease of chronic 
course, which may last for years and be characterized by relapses and 
aggravations, but is entirely curable; it is only in neglected and badly 
treated cases that such persistence may be expected. 

Scar-leaving Sycosiform Dermatosis (Lupoid Sycosis; Ulery¬ 
thema Sycosiforme; S6borrhee depilante). Under these titles has been 
described a somewhat rare affection of the skin of the bearded face in 
men, the symptoms of which at the outset are practically those of 
sycosis vulgaris. In the course of the disease, however, whether in 
consequence of an added infection or as the result of the evolution of 
the malady, a change occurs in which the hair-follicles atrophy and 
considerable scarring results. The scars are often irregularly depressed 
between ridges and linear elevations of the surface. By Unna this 
dermatosis is grouped with a class of disorders to which he has given 
the title of “ulerythemata.” It is possible that the disease may be 
eventually recognized as a tuberculous complication of ordinary syco¬ 
sis. The course of the affection is exceedingly chronic, lasting, with 
alternations of improvement and aggravation, for several years. 
According to Robinson, the inflammation in these cases spreads 
peripherally upward or downward with a narrow infiltrated margin. 
The lesions outside of the follicles may be papular, vesicular, or 
pustular in type. The tendency to extension from a given centre 

15 


226 


DISEASES OF THE SKIN. 


and to irregular scarring are the chief characteristic features of the 
malady. 

Etiology. Sycosis Vulgaris is unquestionably due to either primary 
or secondary invasion of the pilo-sebaceous follicle by micro-organisms. 
Obviously in many cases there is a special reason for the accessibility 
of these germs to the crypts where they are lodged. Shaving, and 
the use in common of towels, brushes, combs, etc., in public establish¬ 
ments (club-houses, barber-shops, hotels), and the employment of 
pillows, lounges, and reclining chairs in public resorts are often the 
origin of the mischief. 

It is encountered chiefly among men after puberty, and in these in all 
social conditions and grades of health. It is not transmissible by hered¬ 
ity. The mere performance of shaving is not known to produce it. At 
times the immediate cause of the disease is recognized when the upper 
lip is constantly irritated by a discharge due to profuse nasal catarrh. 
In other cases, again, all the causes of eczema may be invoked in 
explanation of the result. 

A careful study of many cases suggests that the hairs themselves are 
among the aggravating causes of the disease and the sources of its 
peculiar obstinacy. In health the motions of the free shaft of the hair 
do not irritate the follicle in which it is set; in conditions of disease 
it is quite different. Each free hair operates like a lever upon the 
inflamed ring-tissue which encircles it on its escape from the follicle 
beneath, and thus by the touch of the hand, by the action of brushing, 
by currents of air, or by any agency whatever, a movement may be 
imparted to it. Every such movement teases to a variable degree 
the previously irritated surface beneath; and when estimate is made 
of the hundreds of such movements to which each hair is subjected 
during a period of twenty-four hours, the relative importance of this 
apparently insignificant factor may be appreciated. 

Pathology. The disease is due to pyogenic cocci exciting an inflam¬ 
matory process, which, whether originally follicular or perifollicular 
in seat, may unquestionably extend either toward or from the follicle. 
Sometimes the extraction of the hair is followed by a drop of pure pus, 
which exudes from the follicle, and the root-sheaths of the hair are 
seen to be altered in consequence of the circumscribed follicular abscess. 
At other times the follicle itself is free from disease, and the exudative 
process has evidently expended itself upon the perifollicular or even 
the interfollicular tissues, in which case the papillary layer of the 
derma exhibits the usual phenomena of hyperemia, infiltration, and 
multiplication of protoplasm, with abundant vascular dilatation. 

The micro-organisms recognized (by culture and reinfection) as the 
effective agents in the production of Tommasoli’s bacillogenous sycosis 
were bacilli with rounded extremities presenting an elliptical or ovoid 
appearance. They measured 1.0 to 1.5x0.25 to 0.3^. The symp¬ 
toms clinically resembled those of coccogenous sycosis. 

According to Robinson, the disease always begins as a perifollicular 
inflammation, under the influence of which transuded serum penetrates 
the follicle. Maceration and eventual destruction of the root-sheath 
of the hair result with the ultimate production of pus within and 


INFLAMMATIONS. 


227 


without the follicle. The pus, when the hair remains in the follicle, 
finds its way to the surface by breaking through the epidermis near the 
hair; occasionally exit is obtained between the shaft and the follicle- 
sheath. 

The hair-papilla usually escapes destruction, so that permanent 
alopecia seldom follows. The sebaceous glands are occasionally in¬ 
volved and even destroyed, but the coil glands are affected in excep¬ 
tional cases only. 

Diagnosis. The most important consideration here is the distinction 
between the coccogenous and the hyphogenous forms of disease of the 
region of the beard, upon which point, naturally, the microscope finally 
decides. Still the clinical features of the disease are quite distinct. 
The coccogenous form is recognized: (a) by the greater redness of 
the involved surface ; (b) by the extension of the disease in advanced 
cases to larger areas of symmetrical involvement; (c) by the more 
superficial character of the lesions; and ( d ) by the firm implantation 
of the hairs in their follicles in the earlier periods of the disease, and 
their relative freedom in all cases from fracture and relics in the form 
of stumps. The hyphogenous disease of the hairs is peculiar, in con¬ 
sequence of decidedly less redness of the surface attacked; its frequent 
limitation to a circumscribed area, or to several such, irregularly dis¬ 
persed over a large region; the peculiar u lumpy, tubercular, nodular, 
and uneven” characters of the patch, upon which Duhring has laid 
significant emphasis; and the earlier loosening of the hairs in their 
follicles, as also of the occurrence of fractured hairs and stumps, exhib¬ 
iting usually at the bulb unmistakable evidences of the nature of the 
disease. The malady is often mistaken for syphilis, chiefly on account 
of its deformity; but the pustular syphiloderm is very much less 
chronic in its course, is rarely limited for years to the face exclusively, 
and, when long persistent in one locality, is characterized by ulceration 
and the production of very characteristic crusts. 

Eczema may complicate the coccogenous disease by preceding or by 
following it, but typical instances of the two disorders may be recog¬ 
nized by the occurrence, in the former case, of a discharging disease, 
not usually limited to the region of the beard, characterized by a more 
intense itching, and with marked absence of the papulo-tubercular 
lesions described above. 

The lesions in eczema, moreover, are not invariably perforated by 
hairs. Erythematous eczema of the shaven face is reddish in color, 
and desquamates, after full evolution of the disorder, without pustu- 
lation. 

Treatment. In all cases of sycosis the essential and important step 
is the continual removal of the hairs which, as indicated above, are 
the chief sources of aggravation of the disease. This removal is best 
accomplished by epilation or by shaving, which, though often painful 
at the onset, is soon well tolerated by the sufferer. The majority of 
patients, however object to the removal of the beard, far more on 
account of the consequent greater exposure to view of the deformity 
induced by the disease (then no longer partly masked by the hairs) 
than on account of the distress occasioned by the operation. To these 


228 


DISEASES OF THE SKIN. 


objections there is but one response—the shaving is essential; the 
deformity is rapidly reduced after its successful initiation; the discom¬ 
fort diminishes with each repetition of the process. For the disease in 
patients positively refusing to have the beard removed, whose cases 
are so severe as to require it, the practitioner will do well to decline 
to be responsible. There is no limit to the tedious and obstinate course 
of the malady in the one case, and in the other the results are speedily 
satisfactory, often in the course of a few weeks. 

When there is much tenderness, pain, swelling, pustulation, or crust¬ 
ing, the hairs may first be clipped short, and a bland poultice of oil, 
elm-bark, or of bread and milk applied. The practice in Vienna is 
to substitute for the poultice strips of soft muslin or linen spread 
with diachylon ointment, firmly bandaged over the cheeks, chin, or 
lips for from twelve to twenty-four hours, after which the razor is 
passed over the entire surface. 

The integument which thus becomes visible is usually a reddened 
infiltrated area, with pustules, papules, pustulo-papules, and some 
crusts dispersed here and there over it. This area is best treated by 
hot-water lotions, borated or alkalinized, after exit is given to all 
purulent collections; and then a bland ointment is to be applied at 
night, and a borated dusting-powder in the morning. The subsequent 
treatment is largely that of eczema of equal grade of severity. In 
the more acute periods oleated lime-water, medicated with calomel 
or with zinc oxid, J to 1 drachm (2.-4.) of either to the pint (512.), 
may often be employed with benefit; or for this application may be 
substituted 2 ounces (64.) each of linseed oil, castile soap, and paraffin, 
to the pint (512.) of aqua calcis. Later the Lassar paste or ointments 
may be used, particularly cold cream, to which may be added either 
sulphur, the zinc oxid, or, less preferably, oue of the mercurials. 
Lotions of the mercuric bicblorid, or sulphur, alcohol, cologne-water, 
or iodated glycerin, may be useful in stimulating any indolent patches 
of infiltration. The treatment of these patches is indeed that of chronic 
eczema. 

Epilation is often essential for relief of the disease; and, by many, 
in chronic cases severer methods are employed, including the use of 
green soap, tar, and cauterization with acetic and even with nitric acid. 
Erasion with the curette is to be named in the same category. These 
measures have been employed in aggravated cases,but as the disease is 
certainly curable in a majority of patients without having recourse to 
these heroic methods, they are to be regarded in the light of a dernier 
ressort. It is not necessary in the majority of coccogenous forms of 
sycosis either to epilate or to employ caustics. By repeated and 
frequent use of hot borated water, and the milder stimulants, with 
constant shaving, the desired result is usually within reach. Shaving 
should be continued for nearly one year after all traces of the disease 
have disappeared; and it is a point of some importance to substitute 
for a fatty application a continuously applied borated powder as soon 
as the skin will tolerate the persistent use of the latter. 

Van Harlingen advises for acute cases a wash composed of J- pint 
(256.) of rose-water, to which 1 drachm each (4.) of precipitated 


INF LAMM A TIONS. 


229 


carbonate of zinc and oxid of zinc in powder have been added, with 2 
drachms (8.) of glycerin and dilute liquor plumbi subacetatis. Veiel 
recommends a solution of pyrogallol, one part to fifty, for painting 
over the region affected, followed in the day by emollient cataplasms, 
and in the night by diachylon or weak tannin ointments. Sycosis of 
other portions of the body is to be treated as described for the region 
of the beard. 

Internally, treatment, when indicated, should be of the kind demanded 
by the accidental condition of the patient. It is a matter worthy of 
special attention, however, to purge every previously treated case of 
all suspicion of an artificial element, by withdrawing for a proper time 
all internal medication. The disease is so disfiguring that many patients 
swallow the iodid of potassium, arsenic, and other deleterious drugs 
for months before consulting one who is wiser than they in these 
matters. Exposure of the face to dust, smoke, wind, and other sources 
of irritation should for a time be avoided. 

In the hygienic management of these cases all use of tobacco and 
alcoholic beverages is to be abandoned. Even the drinking of hot 
tea, coffee, and stimulating beverages of other kinds is to be inter¬ 
dicted. The diet should be of the simple character recommended in 
eczema. Inasmuch as many patients suffer from a coincident nasal 
catarrh, hot baths, for patients able to endure the shock, should be 
exchanged for daily cold sponging of the body-surface, followed by 
brisk friction with flesh-brush or with coarse towels. 

In acute cases it may be desirable to begin treatment with a brisk 
mercurial cathartic; the alkaline diuretics advised by authors will, at 
least, do no harm if judiciously employed. The same may be said of 
calx sulphurata and minute doses of calomel in the pustular stages of 
the affection. But in other cases cod-liver oil and iron are demanded 
by the general condition of the patient, usually one of the class exhib¬ 
iting the evidences of “ hospitalism.” No firm believer in the cocco- 
genous etiology of the disorder will, however, expect by these measures 
alone to relieve the disease. 

Prognosis. The disease is entirely curable, and will, in the large 
majority of all cases, either disappear entirely or very greatly be 
improved by judicious treatment. The latter requires the personal 
supervision of the physician and close attention to details. 

In exceptional cases the disorder is exceedingly chronic and obsti¬ 
nate, and requires perseverance on the part of both physician and 
patient to attain the desired end. Relapses are of frequent occurrence, 
due usually to neglect of antisepsis after apparent recovery. In a few 
very rare cases (tuberculosis) there is cicatricial tissue left after repair. 


230 


DISEASES OF THE SKIN. 


[G] Impetigo. 

(Lat. impetere, to rush upon.) 

(Ger ., Krustenfleckte ; Fr ., Dartre Humide.) 

Impetigo is an acute inflammatory affection of the skin, in which discrete, roundish, 
and acuminate or globoid vesicles, of the average size of that of a coffee-bean, 
form and rapidly fill with pus, which, being set free after rupture of the lesions, 
desiccate in characteristic crusts. 

The interesting researches of Bockhart and others have demonstrated 
that the symptoms once designated by the term u impetigo/’ as also 
those of furunculosis and sycosis, are purely and simply the local 
results of infection with the staphylococcus pyogenes aureus and albus. 
The symptoms to which in different cases these several names are given 
differ in consequence of the accidents of location, the sex of the 
patient, and the opportunities for extension of the disease. 

Hebra stated, even in his day, that the pustular, cutaneous affection 
described by authors under the name u Impetigo,” had no existence as 
an independent disease. Unquestionably a long list of disorders hith¬ 
erto described under this term included, in fact, forms of pustular 
eczema. The reasons for retaining the name given above and for 
assigning to it certain peculiar eruptive features are based upon the 
simple fact that the lesions displayed, probably in consequence of the 
operation in a similar way of similar causes, reproduce themselves 
again and again, so as to exhibit the same clinical picture in different 
patients. The convenience of the name impetigo, as descriptive of a 
group of cutaneous symptoms, is, therefore, the sole reason for its 
retention. There is, however, among some dermatologists of the 
French school a tendency to consider impetigo a distinct disease and 
to distinguish several forms, each having a definite cause and capable 
of reproducing itself through inoculation. 

Symptoms. The disease is sufficiently common in practice, being 
observed chiefly in children and young adults of both sexes. In such 
patients, from one to twenty or more isolated and often widely sepa¬ 
rated minute vesicles or vesico-pustules, usually acuminate, appear upon 
the skin-surface either simultaneously or in rapid succession occasionally 
after a slight access of fever. They are speedily transformed into split- 
pea-sized or larger pustules, so rapidly, in fact, that often the early 
vesicular phase is not manifest, the lesions showing as minute pustules 
from the first. When fully developed they are globular, yellowish- 
white in color, discrete, well distended with their puriform, rarely 
bloody, contents, and projected clearly^ from the surface on which they 
rest. They may be surrounded by an erythematous areola, or simply 
be superimposed upon an integument of unaltered color. They may 
persist as pustules, or may burst their contents, drying into a yellowish 
crust resembling honey, or into brownish-tinted concretions which 
adhere with firmness to the superficial and circumscribed base, where 
a slight weeping can be determined. They are much more commonly 


INF LAMM A TIONS. 


231 


observed upon the face, but are recognized elsewhere, always sparsely 
upon the trunk and extremities. The eruption is never in any sense 
generalized, its characteristic feature being the fewness of the lesions, 
rarely exceeding twenty in number, which are scarcely ever grouped, 
and which occur in capriciously selected locations. The subjective 
sensations are slight, and the eruption is more often picked than 
scratched. It is common in dispensary and hospital patients, and 
since they are often the victims of neglect and the subjects of vices of 
nutrition it has been considered the appanage of scrofula. But the 
disease is also encountered in well-nourished and rosy-cheeked children; 
in the latter, when well cared for, the eruption proceeds regularly to 
its natural resolution, while, in the former, it is prolonged and often 
aggravated, thus attracting to a greater degree the attention of the 
physician. The pustules are never umbilicated, never seated upon 
ulcers, and are never followed by cicatrices. 

Etiology. The cause of impetigo is simply infection with pus-cocci. 
The disease occurs rather at the age of childhood than in infancy and 
adult life, a period when the hands are first brought into habitual con¬ 
tact with the face, these quite suggestively being the two sites of elec¬ 
tion. The lesions are very rarely scratched, being more often torn 
with the nails in picking, so that the crusts may be a little blood- 
colored. The habit of picking the nose and other parts of the face 
and the body with unwashed hands is the chief source of mischief. 
In later life the habit of refraining from carrying the hands to the 
face when the former are soiled becomes instinctive. Before this in¬ 
stinct is well established—that is, in childhood—the hands will convey 
to the head any particle of filth or of dust with which they may have 
been brought into contact. 

Pathology. The lesions have microscopically been examined by 
Bockhart and others, who have thus been able to establish clearly the 
coccogenous origin of the disorder. Plainly, each lesion is but a 
distinctly circumscribed and superficial pea- to bean-sized abscess, the 
result of infection with the staphylococcus pyogenes aureus and albus. 
Darier and other French dermatologists describe an Impetigo strepto- 
coocogenata circinata,” in which the lesions closely resemble those of 
herpes iris, and in which the streptococcus only is found. 

diagnosis. To establish the identity of this affection it is necessary 
to define its exact differences from eczema pustulosum. These differ¬ 
ences are: First, the absence of infiltration of the tissues affected; 
second, the absence of itching; third, the failure of the lesions to form 
patches; fourth, the isolation and wide separation from one another of 
lesions distinctly pustular; fifth, the large development and rather per¬ 
sistent character of the pustules; sixth, the evident termination of the 
disease, which does not, as does eczema in many cases, progress to form 
a freely discharging and crusting surface, the pustular being but the 
initial stage of a distinct morbid process. Manifestly, however, an 
impetigo of the sort described is not incompatible with an eczema which 
is often originated by less irritating causes. 

In ecthyma, the pustules are much more formidable in appearance 
than those of impetigo, in consequence of their size, depth, inflamma- 


232 


DISEASES OF THE SKIN. 


tory base, areola, flat, hard, bulky crust, and erosive action upon the 
skin. 

From impetigo contagiosa, impetigo simplex is distinguished chiefly 
by the absence of the evidences of contagion. The lesions of the latter 
are also, at first, strictly vesicular, not vesiculo-pustular nor pustular; 
there is often umbilication, and the pus is auto-inoculable. The lesions 
mav also coalesce. 

Treatment. Individual pustules are to be opened with a comedo- 
needle; the purulent contents gently removed by washing with borated 
water; and the floor smeared with any mild ointment, such as 5 grains 
to a £ scruple (0.33-0.66) of ammoniated mercury to the ounce (32.) 
of cold cream, or the subnitrate of bismuth £ drachm (2.) to the 
ounce (32.); or benzoated zinc salve. Van Harlingen recommends 
the application of a salve on bits of muslin, covering the whole with 
waxed paper. A dusting-powder containing calomel may be sub¬ 
stituted for the salve or be employed afterward. The disease tends 
to spontaneous recovery, if the lesions be not irritated. When they 
are situated within reach of a child's tongue which is constantly thrust 
out of the mouth to moisten them, they may linger obstinately and 
require protection by flexile collodion. 


[H] Impetigo Contagiosa. 

(Porrigo Larvalis, Porrigo Contagiosa, Pemphigus Acutus 
Contagiosus Adultorum [Pontoppidan].) 

Impetigo contagiosa is an acute, inflammatory, contagious disease, characterized by 
the formation of multiple, usually isolated, flattened or slightly umbilicated, 
roundish or ovular, split-pea-sized and larger, vesicles, vesico-pustules, or blebs, 
which terminate by the production of yellowish, slightly adherent crusts. 

In 1862 Dr. Tilbury Fox observed and described the disease now 
under consideration, and he gave it the name “ impetigo contagiosa," 
by which it is most generally recognized to-day. 

Symptoms. The eruption, occurring in infancy, childhood, and early 
adult life, is often preceded by a febrile process, and appears in the 
form of rarely numerous, isolated vesicles, vesico-pustules, pustules, 
or bullae, usually about the face, but also on the neck, the buttocks, 
the hands, or the feet. In severe cases these lesions are surrounded by 
an areola. The lesions are roundish, flat, have the average size of 
that of a split-pea, and become covered in the course of a few days 
with dry, granular, straw-colored crusts, which closely adhere to the 
slightly reddened base on which they rest. Beueath the crusts are to 
be discovered very superficial erosions, which rapidly become covered 
with epidermis. They occasionally coalesce, and their complete invo¬ 
lution requires from a week to a fortnight. When they are of the 
dimensions of bullae a pseudo-umbilication may be observed at the 
apex, produced solely by flaccidity of the roof-wall, which is never 
tied down, as in variola. The contents of the lesions are inoculable 


INFLAMMA TIONS. 


233 


and auto-inoculable, the disease thus spreading from one member of 
a family to another, and also from one part of the body of an indi¬ 
vidual to another part. The mucous surfaces are said to be occasion¬ 
ally invaded. The subjective sensations are mild, the itching rarely 
being severe. The disease runs a tolerably definite course, being usually 
at an end in a fortnight; it may recur. Kaposi states that it is at all 
times accompanied by submaxillary adenopathy. 

The latest studies of this subject indicate with clearness that impetigo 
contagiosa is to share the fate of impetigo simplex, sycosis, and furun¬ 
culosis in the loss of its identity as a disease. The several names are 
here retained as convenient clinical designations of symptom-groups 
the career of which differs in consequence of the ages of the subjects of 
the disorder, their habits, environment, and opportunities for contagion. 

Impetigo contagiosa is a term practically indicative of the symptoms 
of several widely differing causes, all actually resulting in a coccogen- 
ous or hyphogenous disorder. In some cases the irritation is set up 
by the encroachments of the trichophyton. In other cases there are 
pediculi of the occipital region, and the scratching set up in children 
in consequence of attacks of lice furnishes the opportunity for infection 
with staphylococci. In yet other cases the micro-organisms responsible 
for varicella have unquestionably operated to produce the symptoms. 

The several clinical pictures differ on account of the greater or lesser 
diffusion of the contagious elements in each case; for example, there 
may be a few isolated pea-sized and larger vesico-pustules on a single 
hand; or many may be clustered about the mouth and lips; or dense 
greenish crusts may succeed such lesions, over occiput or scalp; or there 
may be much larger pustulo-bullous elements over the legs, torn, 
scratched, and thickly crusted or covered with hemorrhagic incrus¬ 
tations. The disorder is not often seen in private practice, but in 
public patients it is seen among the cachectic, the filthy, and the 
neglected. 

Etiology and Pathology. Kaposi, Piffard, and Geber, all describe 
a microscopic fungus which they discovered in the crusts of the dis¬ 
ease, but neither they nor Tilbury Fox were able to demonstrate the 
existence of a parasite in the contents of the lesions. Plainly, a 
parasitic vegetation on the exterior crust can have no etiological signifi¬ 
cance in this connection. The eruption often occurs during convales¬ 
cence from a more or less actively contagious disease. The antecedence 
of some fever in many cases is admitted by all observers. Duhring 
and Fox have seen it follow vaccinia, and the former admits that some 
connection between the two seems probable. It may occur typically 
in a series of children, each of whom is convalescent from varicella; 
in one interesting case, that of a young woman convalescent from 
confluent variola, the lesions sprang from an integument where the 
pigmeutation of the scars of the last-named disease had not begun to 
disappear. 

Stelwagon, in 1883, 1 reported only six cases of impetigo contagiosa 
out of eighty-eight observed by him following vaccination, and he 


1 Medical Record, December 22, 1883. 


234 


DISEASES OF THE SKIN. 


concludes that the disease is non-parasitic, but is an acute specific 
contagious exanthem, with cutaneous lesions pursuing a definite career. 

Pontoppidan, in 1885, found, as had many before that date, only 
epithelial cells, blood-corpuscles, and detritus in the crusts; never any 
indications of a parasite capable of explaining the etiology of the disease. 

Dew^vre 1 reports a number of successful inoculations and auto¬ 
inoculations practised with the contents of the vesico-pustule, with finely 
powdered impetiginous crusts, and with the products of scraping the 
subjacent erosion. He reports finding reticulated mycelial tubes of 
the thickness of three-thousandths of a millimetre in the rete mucosum 
beneath the lesion. 

In 1884 the author succeeded in producing an almost typical vesico- 
pustule upon his left forearm by inoculation (all due precautions being 
observed) with the moistened debris of crusts. This inoculation was 
done in the Dermatological Clinic, the crusts being taken from typical 
lesions upon the face of a young girl inoculated while under observa¬ 
tion from the lesions of exactly similar character on the face of her 
twin-sister. The lesion on the forearm produced a characteristic 
crust, which in seven days was also used for the inoculation of two 
students then present at the Clinic, in one of whom there was no 
result, and in the other an abortive lesion. 

The disease is contagious, and its lesions inoculable and auto-inocu- 
lable, whether as a coccogenous or hyphogenous process. 

Diagnosis. Impetigo contagiosa is distinguished from impetigo sim¬ 
plex by its frequent pyrexic symptoms; its flat, yellowish, superfi¬ 
cial friable crusts; its vesico-bullous rather than distinctly pustular 
lesions; and its contagiousness. In pustular eczema there are itching, 
infiltration, profuseness of discharge, indefiniteness of duration, coales¬ 
cence of lesions, and extensive bulkier crusts. In varicella the 
lesions are small, much more widely distributed over the body, and 
are vesicular only, rarely bullous. In pemphigus and herpes iris the 
seat, character, and period of evolution of the lesions suffice to estab¬ 
lish the diagnosis. 

Treatment. The crusts are removed and a salve applied consisting 
of cold cream or of vaselin with from 5 to 10 grains to the ounce 
(0.33-0.66 to 32.) of ammoniated mercury. 


[I] Ecthyma. 

(Gr. endv/ua , a pustule ; ekOvo), I burn out.) 

(Ger., Eiterpusteln.) 

Ecthyma is an inflammatory disease of the skin characterized by the formation of 
few or of many, large, discrete pustules, implanted upon a dense, deeply situated 
base; the pus of the pustules dries into dark-colored, firm, bulky, and attached 
crusts, beneath which there may be superficial ulceration and resulting scarring' 

The term <c ecthyma,’’ like several of the titles of chapters imme¬ 
diately preceding, no longer points to a distinct disease. It represents 

1 Arch, de Med. et de Pharm. mil., Sept. 16,1885. 


INFLAMMA TIONS. 


235 


rather a tolerably definite group of symptoms readily separable clinically 
from other affections produced by different causes. The most common 
cause is infection of the skin of the lower extremities with pus-cocci 
after scratching; then follow traumatisms, primary and secondary, 
associated with pediculi of the body (pediculus vestimenti), and com¬ 
binations of these with bedbug-bites; general filthiness of the person 
and clothing of body and bed; and the cachexia of most patients in 
these conditions. The term “ ecthyma ” is, however, not to be dis¬ 
carded, as it suggests to the mind not merely these composite etiological 
factors, but the picture produced as a result in the skin. 

The disease is characterized by the occurrence of one or of several, 
roundish, bean- to filbert-sized, yellowish or reddish pustules, which are 
the result of a distinctly circumscribed, inflammatory process, limited 
to the base of each lesion, or extending from it at the periphery in a 
diminishing hyperemia. This process is distinguished by the forma¬ 
tion at the base of the pustule of an indurated phlegmon, which is 
converted into a loss of tissue involving the corium. The purulent 
or sanguinolent contents of the lesions dry in dark-colored, thick, rough, 
adherent crusts, the color being somewhat dependent upon the quan¬ 
tity of the blood with which they are commingled. On the removal 
of this concretion a minute, shallow, circular pit is discovered, invading 
the true skin to various depths, and lined with a tenacious, puriform, 
and often blood-stained product. When carefully wiped clean this 
solution of continuity, which really constitutes a minute ulcer, is seen 
to have a floor reddish or grayish in color, and indolently granulating. 

The pustules may be acutely or indolently developed, and, when 
multiple, be coincident or successive. They occasion rather a sensa¬ 
tion of heat, burning, and pain than of itching, the latter being 
usually more distinct when the lesions are healing under their crusts. 
Their formation may be preceded by mild general pyrexia. They 
occur at all ages and in both sexes, usually upon the extremities, and 
also upon every portion of the body. 

Etiology. The pyogenic cocci are the efficient causes of most of the 
lesions; practically the agents capable of producing eczema and der¬ 
matitis (traumatism, heat, scratching, parasites, etc.) operate in excess, 
or operate in subjects affected with other diseases, such as anemia, 
asthenia, struma, variola-convalescence, and menstrual disorders. 
Filth and neglect are most common aggravations; in other words, that 
circumscribed cutaneous ulcer will be the angrier and the deeper which 
occurs in the victim of any depressing disease, whose skin is scratched 
with nails begrimed with dirt, and is covered with the effete products 
of the excretory processes. The pus thus produced is in various degrees 
inoculable and auto-inoculable, as is the product of many inflammatory 
processes of similar grade. 

Pathology. The pustule of ecthyma differs in no respect patholog¬ 
ically from the pustule of eczema or the pustule of impetigo, save in 
the severity of the exudative process by which it is produced, and in 
its limitation to the exact seat of external irritation. By the extension 
of that process to the corium there is an actual loss of some of the ele¬ 
ments constituting the papillary layer, the result often being a cicatrix, 


236 


DISEASES OF THE SKIN. 


which contracts as it grows older, and which is, in milder cases, finally 
barely visible as a minute cicatriform punctum. One who frequently 
examines the skin of the entire body with care can usually detect the 
ancient sites of these lesions by their indelible though insignificant 
relics. 

Diagnosis. Ecthyma is liable to be confounded with the other pus¬ 
tule-producing exudative affections, but as the distinction between 
them is largely artificial and based upon the severity of the inflamma¬ 
tory process, there is small danger in consequence. Kaposi well 
expresses the truth in his suggestion that there can be but little objec¬ 
tion to the employment of the term u ecthyma’’ when it is desired to 
characterize precisely the pustular grade of any cutaneous inflammation 
at a given time. The pustules of variola are u ecthymaform,” and 
many of those seen in syphilis possess similar characters; but the his¬ 
tory of the general affection should throw light upon the identity of 
the cutaneous disease. In syphilis, moreover, the ulceration at the 
base of the lesion exhibits the pronounced features of the syphilitic 
ulcer in its secretion, floor, edges, base, crust, and career. The crust, 
in particular, of the flat pustular syphiloderm has the rupioid conical 
appearance which suggests the shell of the oyster, and its underlying 
ulcer is larger and deeper than in ecthyma. In the furuncle there is 
usually a central core; in impetigo the pustules are not deep-seated, 
and there is no ulceration at the base; in impetigo contagiosa the crust 
is superficial, yellowish, firmly adherent, and the lesions are more 
numerous. 

Treatment. The general treatment of patients affected with ecthyma 
is a matter of some importance. A proper regulation of the food and 
hygienic surroundings is not to be neglected. Tonics are frequently 
indispensable, including iron, quinin, and strychnin. The destruction 
of any pediculi and the cleansing of the skin by soap and water will 
often be sufficient to effect a great change. This fact is well illustrated 
in hospital practice, where little patients rapidly improve after a 
bath, followed by inunction with vaselin, and a few substantial meals 
of a nutritious character. When the lesions are abundant the treat¬ 
ment is in general that of pustular eczema. Crusts are to be removed 
after soakings with oil or fat; and the floors of the former pustules, 
after waffling with carbolated water, should be dressed with an oint¬ 
ment containing from 10 to 15 grains (0.666-1.) of the ammonio- 
chlorid of mercury to the ounce (32.) of lard. If the minute basal 
ulcers are sluggish, they may, after careful cleansing, be touched with 
a small swab dipped in a solution of the bichlorid of mercury in the 
tincture of benzoin, 1 grain (0.066) to the ounce (32.). Carbolic or 
boric acid or iodoform may be employed for the same purpose. For 
the salve mentioned above may be substituted one containing 10 grains 
(0.66) of calomel, or J a drachm (2.) of the subnitrate of bismuth to 
the ounce of salve basis 

In every case of the disease it is desirable to inquire whether any 
medicines have been ingested prior to the appearance of the eruption, 
siuce they may be responsible for the lesions. 

The prognosis is always favorable. 


INFLAMMA TIONS. 


237 


[J] Conglomerative Pustular Perifolliculitis. 

Leloir 1 gave this name to an eruption which he described as appear¬ 
ing on the backs of the hands and buttocks and occasionally on other 
parts of the body. 

The disease begins by the appearance of a round or oval, somewhat 
elevated, reddened or purplish plaque, with quite definite outlines. 
The plaque may be no larger than a dime, or it may be the size of a 
silver dollar or larger, and may be elevated to the extent of a quarter 
of an inch. Its surface is smooth or mammiHated, and is perfor¬ 
ated by numerous follicular openings from which pus, or dried plugs 
resembling comedones, may be expressed. The openings of some of 
the follicles may be covered by unruptured pustules. Later the patch 
becomes more phlegmonous, fluctuation can be detected, the follicles 
are more patulous, and pus in large quantity can be pressed out. The 
whole then has much the appearance of a kerion of the scalp, or of a 
flat carbuncle. 

There is usually but one such plaque, though there may be two or 
three, rarely more. Subjective sensations are slight, though there is 
usually some itching and burning. There is no systemic disturbance. 
The disease runs a rapid course, requiring about a week in which to 
develop, after which it remains stationary for a week or two, and then 
disappears under appropriate treatment in from ten to fifteen days. 
More or less deep pigmentation remains some time after the lesions 
heal, but there is no ulceration, and in the few cases in which scars 
are left they are usually very superficial. 

Quinquaud and Pallier 2 describe a variety of folliculitis and peri¬ 
folliculitis which is more chronic, becomes papillomatous, and is 
very stubborn under treatment. Besnier and Doyon 3 describe in 
all five varieties of the disease, including two pseudo-ulcerative, 
serpiginous, and virulent forms which seem to resemble anatomical 
tubercle. 

Etiology. The disease is probably due to contagion, and is seen 
most frequently in those Avho work among horses and other animals. 

Pathology. The process is an inflammation of the follicles, peri¬ 
follicular tissues, and sebaceous glands. Leloir found several forms 
of micrococci and zoogloese in the pus, but he failed to reproduce the 
disease by inoculation-experiments. Quinquaud and Pallier believe 
the active agent to be the staphylococcus pyogenes albus, which acci¬ 
dentally obtains entrance to the follicles and glands. Sabouraud 
found in several cases a large-spored trichophyton. 

Treatment. The treatment is purely local. In the usual milder 
forms daily evacuation of pus, hot boric-acid fomentations, or frequent 
hot bathing, with antiseptic dressings, constitute the only treatment 
necessary. In stubborn forms a stimulating treatment by means of 
strong solutions of nitrate of silver or of carbolic acid, or by means 


1 Ann. de Derm, et de Syph., 1884, vol. v. p. 437, with plates. 

2 "Des perifolliculites suppurees agminees en placards.”. These de Paris, 1889. 

3 Kaposi: Besnier-Doyon, ed. 1891, vol. i. p. 795 


238 


DISEASES OF THE SKIN. 


of the actual cautery, may be indicated. Occasionally it will be neces¬ 
sary to remove the growth with the curette. 


HERPES. 

(Gr. epneiv, to creep.) 

( Fr., Dartre ; Ger ., Blaschenflechte.) 

Statistical frequency in America, 1.66. 

Herpes is an affection of the skin characterized by the occurrence of one or more 
vesicles filled with a clear serum, disposed in groups, usually seated upon an 
inflammatory base, limited to a certain region of the body, and pursuing a definite 
career within a relatively brief period of time. 

The term ( ‘ herpes ’ ’ is unquestionably responsible for a great deal of 
the confusion which has existed with respect to cutaneous diseases. 
By the ancients it was employed, as its etymology suggests, to desig¬ 
nate a disease creeping or extending gradually over the surface or 
within the substance of the skin. By several more modern authors 
the term is employed in a generic sense in a futile attempt to distin¬ 
guish a series of so-called “ herpetic diseases,” and even herpetic diath¬ 
eses from those of a different complexion. The significance which 
attaches to the word in the minds of dermatological authors of to¬ 
day is exceedingly simple, and is limited to the features conveyed in 
the definition given above. It will be seen that the description thus 
embodied is largely that of herpes zoster, an affection which in this 
work is considered separately. 

Symptoms. The disease is declared by the occurrence of millet-seed- 
to coffee-bean-sized vesicles (single or relatively few in number, and 
in the latter case grouped), occurring as epiphenomena of a general 
febrile process, or as symptoms of an idiopathic disease. The lesions 
are usually short-lived, surviving for but a few days, and are filled 
with a clear, serous fluid which may become lactescent. After acci¬ 
dental or spontaneous rupture there is left a slightly tumid, superficial 
excoriation, which at times is characterized by circumscribed hyper¬ 
emia, slight infiltration, or oedema of the base and periphery. The 
subjective sensations are not usually severe, varying between moderate 
pain, itching, and heat. There are occasionally precedent chill and 
pyrexia; but no persistent lesion-relics result from complete involution. 

Herpes Facialis, Herpes Febrilis, “ Cold-sores.” About 
the lips, the mouth, the cheeks, and the ake of the nose, more rarely 
upon other portions of the face, lesions occur singly or in a group, 
possessing the characters described above. Their occurrence is usually 
sudden. Their frequency about the lips has suggested the title 
Herpes Labia lis, under which they are described by several authors. 
The tongue, the buccal membrane, the palate, and the larynx may 
participate in the morbid process; the lesions in such moist situations 
being represented by isolated or by grouped dark-grayish patches of 


INFLAMMA TIONS. 


239 


epithelium that are sensitive and exfoliate. The functions of the 
mouth in articulation and mastication are thus rendered painful. The 
disease is common in acute pneumonia, and in malarial and enteric 
fevers. In these cases, as Kaposi has shown, the occurrence of the 
eruption by no means augurs favorably in every instance, as, never¬ 
theless, a fatal result may follow. 

Often the lesions coalesce, forming in an irregular line of elevated 
epidermis a pea-sized bleb, spread along the vermilion border of the lip 
and distended with a clear serum. The burning and itching sensations 
which accompany the lesions are often marked and distressing. In 
the course of two or three days thin crusts form, the exfoliation of 
which terminates the disorder. 

The connection between labial herpes and rigors has long been recog¬ 
nized, though particular attention has been directed to this relation by 
Hutchinson and Symonds. Beside the trophic disturbance of this 
nature, traumatism, exposure to solar heat, unusual fatigue, a simple 
coryza, exposure to a draught of cold air, and temporary gastric disturb¬ 
ances may suffice to induce the disease. There are patients who can 
produce the lesion at will by tickling the lips with a feather, and in 
some individuals there is an unquestionable susceptibility to the disease. 
The disorder is always short-lived though often recurrent, and the 
superficial crusts which terminate the process are never followed by 
scars. Symmers, of Aberdeen, successfully cultivated a rod- or thread¬ 
shaped micro-organism (solid, filamentous, and without septa) obtained 
from the lymph in vesicles of herpes labialis. 

Labial herpes should not be confounded with the symptoms of La 
Perleche, described on another page. The disease, to which the last 
name has been given in France, is due to a parasite. 

Herpes Progenitalis. This disorder, also termed u herpes pre- 
putialis,” is characterized by the appearance of one or a group of 
transitory vesicles on the inner face of the prepuce, especially upon its 
upper limb, on the glans, on the balano-preputial sulcus, and in the 
adjacent integument; in women, on the hood of the clitoris, the labia 
minora, the inner face of the labia majora, and adjacent surfaces even 
as far removed as the buttocks. 

There is usually a precedent pruritus or a sensation of heat, followed 
by the appearance of one or of several pin-head-sized vesicles seated 
upon a tumid and hyperemic base. Within the preputial sac the lesions 
may either rupture at an early moment or assume the features above 
described as presented upon the mucous membrane of the mouth. The 
resulting oedema of the prepuce is often displayed in an annular tume¬ 
faction encircling the glans, while the labia minora perceptibly project 
from the general vulvar plane. In these localities the floors of rup¬ 
tured vesicles are particularly liable to be irritated (coitus, caustic, 
etc.), and then pus and even blood may be exuded with much angrier 
excoriation and the resulting crusts be of darker shade. In the course 
of a few days even these crusts fall, and the disease is at an end. 
Recurrence is common. 

Rarely, a first attack of herpes in man results in an extraordi- 


240 


DISEASES OF THE SKIN. 


nary sensitiveness of the balano-preputial membrane that persists for 
more than a year. The patients are usually middle-aged men, mar¬ 
ried, and virgin as to venereal antecedents. The membrane is then 
tumid, tense, slightly glazed, and dark red to dark purple in hue. 
Upon any undue sliding of the prepuce over the glans there occurs a 
very superficial fissure, whence a drop of serum oozes. The mem¬ 
brane becomes so sensitive that the passage of the finger over it is 
resented as though the conjunctiva had been touched. Unusual fric¬ 
tion by the clothing or the use of a stimulating lotion is followed by 
intense pain and aggravation of symptoms, and the price of coitus is 
several days’ rest in bed. 

Naturally, the diagnosis of herpes progenitalis is between chancroid 
and chancre. The latter will be manifested by its induration, its 
period of incubation, and its characteristic inguinal adenopathy. The 
chancroid, whether in pustular form or as an inoculated abrasion, is 
ab origine ulcerative in tendency, capable of auto-inoculation, and 
often accompanied by sympathetic, inflammatory, or virulent bubo of 
one side. Balanitis, with its puriform secretion and superficial patches 
of reddened epithelium, is readily distinguished from herpes progen¬ 
italis by its symptoms, though the two disorders frequently coexist. 

The practitioner should never forget that the patient who exhibits 
a herpes of the genital region to-day may have been inoculated at the 
site of the lesion, which to-morrow or later may take on the chancrous 
modification. The rule to be followed, then, is very simple. No 
individual with a progenital herpes can be assured of immunity against 
syphilis until the longest period of incubation of the syphilitic chancre 
has elapsed since the date of the last suspected exposure. 

Herpes progenitalis is almost universally the result of naturally or 
unnaturally induced sexual erethism. Its occurrence in an individual 
virgin as to such antecedents may be due to the causes efficient in the 
production of herpes facialis. Unna, 1 in an interesting paper on this 
subject, has conclusively shown that, though relatively rare in chaste 
women, it is of common occurrence in prostitutes. 

Diday and Doyon, 2 who have given special attention to the subject, 
believe that true herpes of the genital region is always of the recurrent 
type, and well marked by its special course, career, and consequences. 
All others of a false type are divided by them into (1) an irritative form, 
seen in women as the result of vaginal discharges, sexual irritation, 
etc.; (2) a pseudo-membranous or diphtheroid form, also occurring for 
the most part in women, vesicular and even bullous in lesions, the 
rupture of which is the signal for pseudo-membranous transformation; 
and (3) a neuralgic form, which is merely zoster of the genital region. 

Treatment. The milder forms of herpes occurring about the lips 
and the genitalia require the simplest treatment. Sponging with pure 
water, as hot as can comfortably be tolerated, is best followed by local 
use of a weak lead lotion, rose ointment, or zinc salve. About the 
lips it is well to protect the lesions with flexile collodion or isinglass 


1 Journ. of Cutan. and Ven. Dis., August, 1883. 


2 Les Herpes genitaux, Paris, 1886. 


INF LAMM A TIONS. 


241 


plaster. Occurring upon the genital region, the lesions are to be pro¬ 
tected by the interposition of a pledget of lint, or a borated or salicy- 
lated dusting-powder. As a rule, ointments are unsuited for the moist 
mucous surface of the genitals, the odorous emanations from most dis¬ 
eases of such parts being disagreeably retained by all grease-containing 
compounds. Lotions answer far better, and they may be made stimulant 
with alcohol; astringent with tannin, the suphate of zinc, or the sulphate 
of copper; painless with opium or coca'in; and antiseptic with carbolic 
acid or corrosive sublimate. Prophylaxis by the local use of aromatic 
wine, or tannin and brandy, with continence, is a matter of importance. 

Herpes Iris. The behavior of the lesions in herpes iris differs 
somewhat from that of those just described, and this has led several 
authors to consider the affection as a separate and distinct disease. As 
there is, however, some doubt respecting the question whether herpes 
iris should not be relegated to the dominion of erythema multiforme, 
it is assigned a provisional position in this connection and is also con¬ 
sidered in the chapter devoted to Erythema. 

The symptoms at the onset are the occurrence of one or of several 
vesicles or vesico-papules, which pursue their usual rapid career in two 
or three days. Upon the hyperemic ring which surrounds these lesions, 
a second and even a third and fourth circlet of similar lesions form, 
each pushing the areola further to the periphery of the patch. The 
older lesions are in full retrogression while the newer are in the pro¬ 
cess of evolution; and the red blush which surrounds the earlier is 
undergoing color-changes from vivid to paler hues, while the zone of 
the latest vesicles is assuming its intensest shade. The lesions are pin¬ 
head- to pea-sized, rather persistent and firm, and they terminate more 
often by resolution than by rupture and crusting. The concentric and 
parti-colored rings may make up a single patch an inch or more in 
diameter, or several such patches may form upon the surface of the 
integument. In the latter case the central disk of some of the patches 
will be seen to be made of confluent lesions. The eruption is most 
commonly situated upon the extremities, especially over the dorsum 
of the hands and the feet, in which situations, especially when sym¬ 
metrically developed, it is always, according to Kaposi, more nearly 
allied to erythema multiforme. It is, however, also rarely seen upon 
the face. The subjective sensations produced are usually trifling. 
Atypical forms occur where the lesions are imperfectly developed from 
papules, and also where, in consequence of an unusual exudation of 
serum, bullse appear. 

The points in which herpes iris most resembles erythema multiforme 
are: the variegation of the tints in the peripheral integument (whence 
the name iris); its localization upon the extremities chiefly; its occa¬ 
sional symmetry; its frequency in young adults; and its tendency to 
occur in the spring and autumn. Furthermore, herpes iris differs 
from other forms of herpes in the absence of a precedent febrile state 
or neuralgic pain; in its avoidance of regions near the mucous outlets of 
the body (preputial orifice, vagina, mouth); and in behavior of the 
vesicular lesions after attaining their full development. 

16 


242 


DISEASES OF THE SKIN. 


The affection is evidently one upon the border-line between herpes 
and erythema multiforme, and might properly be considered under 
either title. Its existence is another evidence of the impossibility of 
drawing hard and fast lines between all clinical symptoms presented 
by different diseases. 

Herpes iris can scarcely be mistaken for other affections, in conse¬ 
quence of the elegance with which its lesions are disposed. Pemphigus 
simplex and pemphigus foliaceus differ decidedly in their career, how¬ 
ever much they may, at the outset of exceptional cases, present certain 
points of resemblance. 

The affection tends to spontaneous recovery, and requires no treat¬ 
ment. A dusting-powder may be applied over the surface, if need be, 
to protect the lesions from accidental rupture. 

Herpes Gestationis (or Pemphigus Hystericus) is a name which 
has been employed to designate erythematous, papular, vesicular, and 
bullous lesions, accompanied by marked pruritic and burning sensa¬ 
tions, occurring usually upon the extremities, but also upon other parts 
of the body. The subjects are usually pregnant or hysterical women, 
who are said to exhibit recurrent attacks in successive conditions of 
pregnancy or neurotic disorders. The view of Duhring, that this 
disorder should be included under Dermatitis Herpetiformis should 
be accepted. 


HERPES ZOSTER. 

(Gr. ZooTTjp, a girdle; Lat. cingulum , a girdle.) 

(Shingles, Zona, Zoster, Ignes Sager, Hemizona. 

Ger ., Feuerguertel.) 

Statistical frequency in America, 1.15. 

Herpes zoster is an acute exudative affection of definite career, characterized by the 
occurrence of groups of firm and distended vesicles, preceded, accompanied, or 
succeeded by neuralgic sensations, usually monolateral in distribution, and followed 
in some cases by persistent cicatrices, the cutaneous symptoms being always limited 
to an area of the skin supplied by a twig of one or more of the cranial or spinal 
nerves. 

Symptoms. The eruption in this affection is usually preceded, for a 
period lasting from a few hours to days and even weeks, by malaise or 
neuralgic sensations of moderate or of severe intensity. " These sen¬ 
sations are usually limited to the area of the integument subsequently 
or coincidently displaying cutaneous lesions; but there are exceptions 
to this rule, as the pains are at times experienced elsewhere. Often, 
though, limited to the region about to be attacked, the pain occurs 
where it is experienced in other neuralgias, at the points indicated by 
Romberg as corresponding with regions where cutaneous branches are 
given off by the nerve-trunks. 

According to habre, the essential lesion, always present even when 
vesicles are not seen, is the first macular efflorescence of the disease, 


INF LAMM A TIONS. 


243 


that appears in the form of brilliant red erythematous macules, groups 
of which, from six to ten in number, appear in the tract supplied by 
the affected nerve. The vesicles, which are generally regarded as 
more characteristic of the disease, appear afterward in from a few 
hours to a day or more, spring from the macules, and are accompanied 
by a sensation of heat. These typically perfect, isolated vesicles vary 
in size from that of a rape-seed to that of a coffee-bean. They appear 
in groups corresponding with the groups of the macules, from eight to 
a dozen in a single cluster, and occur successively, the individual 
members of each attaining maturity simultaneously in about one week, 
while the succession of others may prolong the period of efflorescence 
to an entire month. 

The lesions, when fully developed, exchange their early limpid con¬ 
tents for those of a lactescent or a puriform character. They project 
well from the widely hyperemic base from which they spring, are 
tense from complete distention, and have no tendency to spontaneous 
rupture, so firm is their roof-wall. When abundant, they may coa¬ 
lesce. Involution is accomplished by desiccation and the formation of 
yellowish-brown crusts, whose fall is succeeded in certain cases by 
indelible scars. 

Several variations from the type thus described require notice. The 
vesicles may be few and typical, or numerous, abortive, and transitory, 
or differ in type as they may be transformed into veritable pustules or 
bullae, or become filled with blood from capillary hemorrhage. In the 
latter event there is a still further departure from the type in their ten¬ 
dency to spontaneous rupture and subsequent ulceration. According 
to Kaposi, it is in the latter class of cases only that cicatrices form, 
but this statement, in view of many clinical observations, must be 
accepted with reserve. 

In intercostal zoster there may be ganglionic swellings in the infra- 
and supra-spinous fossae. The vesicles occasionally become gangrenous 
in this and other varieties of the disease. 

Authors have established a number of clinical varieties of herpes 
zoster, merely differing as to symptoms, such as acute febrile, apyretie, 
subacute, and even chronic and recurring forms. A bluish appearance 
of the eruption in some parts suggested the name u black herpes;” 
blood in the vesicles, a hemorrhagic form; and the occurrence of gan¬ 
grene has added an additional distinguishing term. 

The anomalies of nervous significance are: extraordinary persistence 
of neuralgia after involution of the cutaneous lesions; neuralgia of an 
intense and intolerable severity at any period of the disease; painful 
anesthesia of the skin; paretic and paralytic phenomena with resulting 
muscular atrophy; and, in zoster of the head, falling of teeth and 
hair. 

The vesicles of herpes zoster are always produced in those areas of 
integument supplied by sensory nerves proceeding from the cerebro¬ 
spinal tract, a circumstance which explains their usual limitation to a 
single lateral half of the body. This limitation is rarely observed 
exactly at the median vertical line, as a few lesions can usually be 
seen surpassing this boundary. The terms zoster capitis, zoster 


244 


DISEASES OF THE SKIN. 


brachialis, zoster occipito-cervicalis, etc., are used to distinguish the 
special regions involved in the disease. 

The fact that the majority of all cases are due to disease of the gan¬ 
glionic nervous system, and not to disease of the spinal cord, explains 
the more frequent occurrence of zoster in the upper portion of the body. 
Individuals are commonly subject to but one attack of herpes zoster in 
a lifetime, though, as usual for all general laws, there are the few excep¬ 
tions which prove the rule. 1 The same may be said of double attacks, 
those involving simultaneously the two lateral halves of the body, 
instances of which are occasionally recorded. These attacks may be 
complete and symmetrical, or multiple and not symmetrical, or bifid, 
when there is simultaneous involvement of several branches of one nerve 
or several nerves. The anomaly occurs most often in the subjects of 
syphilis. 

Barensprung recognized the nine varieties of this disease given 
below, the difference in each having a purely local significance. 

Zoster Capillitii depends upon involvement of the second branch 
of the fifth pair of nerves, and its lesions occupy the anterior and 
posterior portions of the scalp. 

Zoster Frontalis occurs in the area supplied by the supra-orbital 
nerve, which springs from the first branch of the trigeminus. Its 
lesions extend from the upper eyelid to the vertex, and spread in a 
fan-shaped figure over one-half of the brow, forehead, and scalp. 

Zoster Ophthalmicus may be a severe and dangerous manifesta¬ 
tion of the disease, being often complicated by agonizing neuralgia, 
formidable involvement of all parts of the eye, even resulting in 
panophthalmia, ulcerative keratitis, pyemia, meningitis, and death. 
Typical cases of zoster of this region may not, however, exhibit a single 
untoward symptom of the disease. 

Zoster Facialis depends upon involvement of the sensory nerve- 
fibres of the trigeminus distributed to the face, its lesions being dis¬ 
played over one cheek, the side of the nose, the half of the lip, or 
of the chin. The facial and seventh nerves may chiefly be affected. 
Care must be taken in cases of this variety not to confound the disease 
upon the nose with acne, or with painful tertiary syphilitic lesions, 
errors in diagnosis that have occurred. When the lower jaw is involved, 
there may be severe toothache, dysphagia, and fall of the teeth, with 
great resulting deformity. 

Zoster Nuch.^e, seu Collaris, occupies the region extending 
forward from the cervical vertebrae to the clavicle, or upward toward 
the occipital region and the auricle. 

Zoster Brachialis occupies the region from the last cervical and 
first dorsal vertebrae over the supra-spinous scapular region and the 


1 For an excellent rtmml of the literature of the exceptional cases see “ Recurrent Zoster,” by 
Dr. Joseph Grindon. Journal of Cutan. and Gen.-Urin. Dis., May, 1895. 


INF LAMM A TIONS. 


245 


contiguous portions of the upper arm. Rarely, even the skin of the 
fingers and that over the first and second ribs is involved. It is a 
common and usually a mild form of the disease, and is characterized 
by a peculiar isolation of the vesicular groups. It occurs also with 
lesions of exclusively brachial distribution. Thomson, of London, 
reports brachial zoster with involvement of the right internal cuta¬ 
neous nerve where two groups of vesicles appeared in the palm of the 
hand. 

Zoster Pectoralis is the most frequent form of the disease, from 
which the common name u shingles” originated. The eruption occurs 
below the first dorsal, covers the skin of the thorax as far as the lumbar 
vertebrae, and extends from the spinal column behind to the sternal 
region in front. Two, three, or more of the intercostal nerves in this 
region are commonly involved, and the neuralgia resulting has fre¬ 
quently been mistaken for the pain of pleurisy. Children are more 
apt to display this form than any other variety of zoster. 

Zoster Abdominalis. The area here involved extends from the 
lumbar vertebrae to the median line of the abdomen. Zoster abdom¬ 
inalis is usually much less pronounced in its features, and the exanthem 
less abundant than in the variety of the disease just described. When 
constipation exists defecation may be attended with considerable pain. 

Zoster Femoralis covers the buttocks and sacrum, and extends 
along the thighs, sweeping from behind forward and from above 
downward as far as the popliteal space; in some cases involving the 
leg and foot. The penis, the scrotum, the labia, the vestibulum 
vaginae, and the anus may then exhibit unilaterally arranged vesicles. 

The scars left by zoster are characteristic. Not only are they limited 
to the original seat of the disease, but they have also a peculiar indented 
look, as if made by a nail-set and hammer. They are particularly 
angular in outline, and do not exhibit the dead-white color of many 
cicatrices. 

Etiology. Herpes zoster occurs in both sexes, and in the young as 
well as in the old, though it is rarely seen in infants. It seems to be 
somewhat influenced by the seasons, as cold and damp weather serves 
to increase its frequency in those susceptible to it. A large list of 
other depressing agencies are named as effective in its production, such 
as certain poisons, carbonic-acid gas, belladonna and atropin (Mackin¬ 
tosh), arsenic (Baker, Dyce Duckworth, Hutchinson), pyemia, carci¬ 
noma, fever, measles (Gerhardt), pulmonary inflammations (including 
phthisis), septicemia, hemorrhages, traumatism, and malaria. It has 
also followed vaccination, the passage of electrical currents, the extrac¬ 
tion of teeth, an accidental prick by a thorn, the tapping of hydatids, 
and gunshot-wounds of the body. Inasmuch as no one of these causes 
can be cited as certainly effective in all cases, it can merely be said 
that any influence sufficient to induce inflammation of a sensory nerve 
or its ganglion may be followed by the objective signs of the disease. 


246 


DISEASES OF THE SKIN. 


Zoster occurs occasionally in small epidemics; some observers strongly 
favor the theory of infection. 

Pathology. The disease exhibits in some cases unmistakable evi¬ 
dence of its association with a descending interstitial neuritis, but may 
be associated with any irritative action in any portion of the nervous 
tract from central to peripheral limit. The researches of Barenspruqg, 
Rayer, Wagner, Charcot, Kaposi, and others have demonstrated with 
sufficient clearness that in zoster there are always, at some point in the 
corresponding nervous tract (cerebral or spinal centres, ganglia, or the 
nerves themselves), pathological changes. These changes are: enlarge¬ 
ments, hemorrhagic effusion, separation, softening, or destruction, of 
the nervous bundles, with hyperemia, infiltration, and multiplication 
of the elements which surround the latter. 

Fig 47. 


Longitudinal section of the third spinal ganglion of the right lumbar region from a case Ox 
lumbo-inguinal zoster: a,a, ganglion, the black spots correspond with pigmented ganglion-cells; 
the dark lines with engorged vessels; a,b,c,d,e, fatty tissue surrounding the ganglion: 6,6, nerve- 
filament divided longitudinally at the points of entrance and exit; c,c, divided perpendicularly. 
(After Kaposi.) 

Sometimes the ganglia and nerves are both reddened and swollen at 
the site of the inflammatory affection; at other times the ganglion alone 
is large and soft, or is fatty from metamorphosis of its cells. Accord¬ 
ing to Curshmann and Eisenlohr, the process may begin in the blood¬ 
vessels of the nerve-sheath, as well as in the perineural connective 
tissue, the nerve-substance being quite intact. This is termed “ acute 
nodose perineuritis,” as small nodules were recognized by these ob¬ 
servers in one case along the cutaneous branches of the axillary nerve. 
Lassar , 1 in a post-mortem examination of three cases, found the nerves 
thin, flattened, and of a transparent reddish-gray color contrasting 
with the normal white. There had been desquamation to the extent 
of replacing the normal structure with connective-tissue elements. 
Similar changes were recognized in ganglion cells and fibres. 



Centralbl. f. d. med. Wissensch., December, 1883. 


INF LAMM A TIONS. 


247 


According to Biesiadecki and Haight, the cutaneous lesions originate 
in the deeper portions of the rete, precisely as in other vesicular dis¬ 
eases. The exudate from the hyperemic corium, especially its papil¬ 
lary layer, presses upward into the rete, the epithelia of which are thus 
separated and vertically elongated. The serous exudation finally 
reaches a point where the horny layer is forcibly raised from its bed 
to form the roof of the vesicle. The mechanical destruction of the 
papillary layer of the corium by the hemorrhagic or the purulent con¬ 
tents of the lesions results in a solution of continuity, which is healed 
ouly by granulation and the necessary formation of a cicatrix. 

Robinson, studying the same phenomena in the skin, also finds the 
epithelia lengthening into bands by tension, the lacunae between them 
being distended with serum and a few round cells. Often the vesicles 
form about the hair-sacs. As the exudation increases, the rete-cells 
are progressively separated, and finally are discovered free in the 
exuded fluid, though some, in changed form but still connected, may 
be found in the upper part of the vesicle. Except at the margin, the 
mucous and horny layers are separated by the exudation. At first 
many-chambered, the vesicle represents finally a single chamber filled 
with serum containing rete-cells and a few pus-cells, the latter increas¬ 
ing in number as the vesicle changes its type. Its base at first rests 
upon the lower portion of the mucous layer; later, upon the corium 
itself, where all signs of papillae are absent. In the vicinity of the 
vesicle the papillae and corium are infiltrated and the vessels are dilated, 
this peripheral change not extending deeply into the corium. Beyond 
this area, however, which is infiltrated in a columnar-shaped region, 
usually about a hair-follicle deep in the subcutaneous tissue, Robinson 
recognized a perineuritis characterized by a round-celled infiltration 
within and around the neurilemma. 

Leloir draws a distinction, which seems to have a basis in fact, 
between a zoster of purely tropho-neurotic origin, occurring in the 
area of distribution of a profoundly injured nerve, and that form of 
the disease in which nervous and ganglionic changes, if there be such, 
are but superficial and transitory. The opinion is gaining ground that 
a disease which occurs, as a rule, but once in a lifetime, must acknowl¬ 
edge some influence behind even its best-marked alterations in the 
nervous system; must, in other terms, resemble the specific exanthe¬ 
mata. 

The fact that Valdettaro and others produced septic effects after 
inoculation of cultures of micro-organisms recognized in the pus 
obtained from certain vesicles in zoster, has led to the inference that 
there is also a septic form of the disease. 

Diagnosis. The vesicles of herpes zoster are not rarely confounded 
with those of eczema; but the distinction between the two is always 
very readily established. In eczema there is itching but no neuralgia; 
the vesicles tend to rupture spontaneously, and never persist, as they 
do in zoster; eczematous lesions are also smaller, more acuminate, 
and rarely distinctly limited to the lateral half of the body. Herpes 
simplex is frequently recurrent, herpes zoster almost never; herpes 
simplex is exceedingly liable to spread around the mucous outlets of 


248 


DISEASES OF THE SKIN. 


the body, and on either side of the latter, while zoster only reaches 
such regions after extension from other parts, and is then almost invari¬ 
ably monolateral. Its lesions are, moreover, never grouped in the 
concentric circles of herpes iris. 

Treatment. The local treatment indicated in herpes zoster is protec¬ 
tion of the vesicles from rupture and relief of pain. These ends are 
best accomplished by thickly dusting the lesions with an opiated pow¬ 
der, such as Anderson’s powder, with the sulphate of morphin, 2 
grains (0.133) to the ounce (32.); lycopodium with powdered opium, 
etc. Rupture of the lesions should never be practised. Over the 
entire affected surface should be gently laid a sheet of soft lint or of 
antiseptic cotton, its meshes being also filled with the powder, and a 
bandage, when practicable, smoothly bound over the whole. In the 
milder cases, nothing more than this treatment is needed from first to 
last. In other cases, where the lesions have ruptured and their bases 
have undergone erosive or ulcerative changes, oleated lime-water 
with zinc oxid, belladonna and opium, or morphin, should be applied 
and be covered with Lister protective. Carbolated and anodyne 
ointments may also be used, especially toward the latter part of the 
history of the case. 

Lotions of lead-water and laudanum, or the u lead-and-opium wash” 
may be employed. Van Harlingen recommends J ounce (16.) each 
of precipitated zinc carbonate, powdered zinc oxid, powdered starch, 
and glycerin, shaken up in a J pint (256.) of water. 

Duhring speaks well of collodion with morphin, in the strength of 
10 grains (0.666) to the ounce (32.). Kaposi warns against the use 
of diachylon ointment. Generally, it may be said that ointments 
should be the last resort, but those containing from 10 to 20 grains 
(0.66-1.33) of the aqueous extract of opium or of belladonna, to the 
ounce (32.) will at times give relief from pain. The oleates of cocain 
and menthol have been used locally with great advantage in meeting 
the same indication: 

No remedy for internal use is known to have the power of aborting 
or of shortening an attack. Quinin is certainly indicated and does no 
harm, but quinin and strychnin in full doses have alike proved quite 
inefficacious. Other remedies employed are the phosphid of zinc in 

grain (0.022) doses, repeated every three hours, and, if iudicated, 
in combination with ^ (0.011) grain of the extract of nux vomica; 
arsenic (Kaposi); and the tonics in general. Anodynes, by mouth or 
by hypodermatic injection, are often indispensable. Inasmuch as many 
patients consider the attack a trivial matter, it is of some consequence 
that they be warned of the possibilities of the future, and that they be 
confined to an apartment of equable temperature where they are not 
exposed to atmospheric changes. This measure is of special importance 
in all the zosters of the face. A skilled oculist should be consulted in 
all cases involving the eye. 

Other measures useful are: first in value and importance, a contin¬ 
uous galvanic current of between two and three milliampSres, two or 
three times daily for ten minutes at a sitting; next, blistering or dry¬ 
cupping, or in sthenic cases wet-cupping over the root of the nerve; 


I NFL A MM A TIONS. 


249 


lastly, a dry dressing with biniodid wool. The stronger applications— 
such as 90 per cent, alcohol; or resorcin two parts, alcohol one hundred 
parts; or 1 per cent, of menthol or of thymol—may be useful when 
other measures fail. As a rule, the exanthem in zoster is preferably 
dressed dry and amply protected with lint, medicated wool, or an 
impermeable tissue. 

Prognosis. Zoster usually runs a benign course. The prognosis 
may, in exceptional cases, be in the highest degree grave. Many 
severe cases have occurred, where patients, after years of intense suffer¬ 
ing, have resumed the occupations of life, physical wrecks of their 
former selves, their faces indented with profound scars, and the vision 
of one eye impaired or utterly ruined. Rarely the termination is fatal. 


DERMATITIS HERPETIFORMIS. 

Dermatitis herpetiformis is a rare but well-defined febrile disorder, characterized by 
the appearance upon the skin of multiform lesions, differing in different cases t 
macular, papular, vesicular, pustular, or bullous in type, attended by subjective 
sensations of itching and burning, the disease at times being grave in character 
and fatal in termination. 

Dermatitis herpetiformis should be named Dermatitis multiformis, 
as the latter term is more descriptive of its phenomena. It is a malady 
which, in one form or another and under different titles, has long 
been recognized and described. The credit, however, of clearly estab¬ 
lishing its identity, and of recognizing one process as differently 
expressed in the several observations of others, is largely due to 
Duhring, of Philadelphia. 1 

The identity of the disease as a special pathological process has only 
lately been established. Much investigation is yet required before 
settling definitely many of the interesting questions it presents for 
consideration. Duhring regards its vesicular and bullous forms as iden¬ 
tical with “herpes circinatus bullosus” (E. Wilson); “pemphigus 
prurigineux ” (Hardy); “herpes gestationis” (Milton, Bulkley, and 
others); “pemphigus” (Klein); “pemphigus circinatus” (Payer); 
“herpes phlyctenodes” (Gibert); “pemphigus aigu prurigineux” 
(Chausit); “herpes iris” (Jarish); “ fatal pemphigus-like dermatitis” 
(Mayer); “peculiar skin eruption recurring during pregnancy” (Os¬ 
wald); “bullous eruption of a peculiar character” (Leigh); “pem¬ 
phigus compost” (Devergie); and “hydroa” (Jones, Bulkley, and 
others). 

Symptoms. Constitutional symptoms are usually slight or wanting, 
but the first appearance of the disease and the succeeding attacks or 

1 Dermatitis Herpetiformis ; its relations to so-called Impetigo Herpetiformis. American Jour¬ 
nal of the Medical Sciences, October, 1884. 

Dermatitis Herpetiformis, case of, caused by nervous shock, etc. Ibid., January, 1885. 

Case of Dermatitis Herpetiformis, illustrating the pustular variety of the disease. Journal of 
Cutaneous and Venereal Diseases, vol. i. No. 8. 

Case of Dermatitis Herpetiformis with peculiar gelatinous lesions. The Medical News, March 
7, 1885. 

Notes of a Case of Dermatitis Herpetiformis, etc. New York Medical Journal, Nov. 1884. 

A Case of Dermatitis Herpetiformis (Bullosa). New York Medical Journal, July, 1884. 


250 


DISEASES OF THE SKIN. 


exacerbations are frequently announced by malaise, sensations of chilli¬ 
ness, decided rigors, or alternations of cold and hot sensations, with 
systemic disturbances. The skin usually is then the seat of pruritic 
or of burning sensations followed in the course of from twelve hours 
to two days by the appearance of the exanthem, which may be macu¬ 
lar, papular, tubercular, vesicular, pustular, or bullous in type, or be 
combinations of these lesions recurring in every variation. The lesions 
may be cutaneous, muco-cutaneous, or mucous in situation. 

The macular form of eruption appears in small-coin- to palm-sized 
patches, irregularly rounded, coalescing, well- or ill-defined as to outline, 
and slightly raised, suggesting the lesions of erythema multiforme or 
urticaria. Imperfectly defined maculo-papules, papules, and papulo- 
tuberculous lesions, varying in shape, size, and firmness, may also spring 
from or be intermingled with the reddish maculations described above. 

In typical development, however, the disease presents cutaneous 
symptoms of herpetic type. Flat, slightly elevated, hard, angular, 
irregularly outlined vesicles may appear, pin-head- to bean-sized, and 
tensely distended with their contents. They may be pale yellow or 
darker in color, and with or without areolae. When bullae form they 
may be sparse, or be plentiful, and be bean- to egg-sized, with cloudy, 
lactescent, hemorrhagic, or purulent contents. Pustules, when pres- 
eut, are single or are clustered, pin-head- to bean-sized lesions, flat, 
and each surrounded by a livid areola. When evolution is complete, 
segments of rings, or distinct rings, of new minute or large pustules 
surround those first formed, and in less than a week they rupture and 
become covered with a crust, which is flat, adherent, and yellowish, 
greenish, brownish, or blackish in color. When there is coalescence, 
a large-coin-sized pustule and crust may result, and even large patches 
of these coalesced lesions may form. The lesions may number from 
a score or fewer to hundreds. 

The imprint of the cutaneous symptoms is multiformity and recur¬ 
rence. Vesicles, pustules, and bullae without order or regularity of 
evolution or of recurrence, appear at one and the same time, in rapid 
or in slow succession, and, without fixed intervals of appearance, for 
months at a time. 

Generally, however, a prevalence of one special type of lesions may 
be noted during a single period of outbreak or of recurrence. This 
prevalence is in the direction generally of lesions of an herpetic type, 
viz., the vesicular and the bullous, though less frequently one of the 
other types may predominate, and rarely vesicles may be absent. 

As a result of the conditions described above a peripheral new 
formation of lesions tends to produce marginate patches where group¬ 
ing occurs, the groups, however, being interspersed with diffusely 
disseminated lesions of various types. The irregular, angular, or 
stellate forms of the lesions containing fluid, are highly suggestive. 
Pigmentation and infiltration of the skin are commonly noticed. The 
subjective sensations of burning increase and diminish as cutaneous 
lesions are multiplying or are disappearing. The pruritus is in some 
cases more severe than in eczema, and the traumatisms of scratching 
add greatly to the multiform features of the disease. 


INFLAMMA TIONS. 


251 


The disease lasts for months and even for years. Dull ring reports 
some cases lasting from five to fifteen years, with periods of relative 
or of entire immunity. 

In one of Dull ring’s cases there were thumb-nail-sized, raised but 
flat, golden-yellow-colored lesions, of very firm consistency, containing 
a similarly colored, thick, consistent, gelatinous pulp. This author 
states that he has observed them before in several cases of the disease. 

When the oral cavity is invaded there appear upon the sodden and 
macerated mucous surface pustules and bullse, which rupture, leaving 
raw and unhealthy-looking erosions, even sloughing patches of mucous 
membrane. Crusts form about the nares and the lips, and the stench 
from the patient is intolerable. In the same way the vulva, the anus, 
and the prepuce may be surrounded by vesicular and bullous lesions 
which form also on the mucous surfaces adjacent, and pursue a course 
similar to that recognized in the mouth. 

In grave cases, as the skin symptoms exhibit a marked aggravation, 
the systemic condition changes for the worse. After a low fever alter¬ 
nating with chills and accompanied by progressive cachexia and emaci¬ 
ation an intermittent diarrhea or a pneumonia may close the scene. 
The repulsive appearance of the patient at the last, in severe cases, is 
as formidable as that in the fatal issues of confluent variola or of severe 
pityriasis rubra. 

The diagnostic features of the disease are: chronicity, with or with¬ 
out remissions or intermissions; multiformity of the lesions, among 
which those of herpetic type usually predominate; the tendency of 
the lesions to appear in groups or patches ; the very marked capricious¬ 
ness and variableness of the recurrences and exacerbations in their times 
of appearing, and in the nature, extent, and severity of the lesions; 
itching, often intense; and more or less pigmentation. 

The etiology , pathology , and proper mode of treatment of this disease 
are not yet fully understood. In some cases disorders of the nervous 
system must be admitted as efficient in its production. Duhring reports 
a typical case following nervous shock. One patient had lost a 
number of children by accident. Renal disease has been demonstrated 
in a number of cases. The malady occurs in early and in middle 
adult life in both sexes, though in women decidedly oftener than in 
men, and, among the former, preferably among those in the puerperal 
and pregnant states. Unquestionably the phenomena of the disease in 
the later stage of fatal cases are septicemic in origin. 

Internal treatment has been directed to meet the indications pre¬ 
sented. Of great importance are hygienic measures with a view to 
maintaining the patient’s general health. All excesses, excitement, and 
everything tending to interfere with the equilibrium of the nervous 
system should be avoided. A nutritious but simple diet, regular habits 
of living, with sufficient outdoor life and exercise, are all of great value. 
Medication is directed chiefly toward improving the tone of the ner¬ 
vous system, for which purposes strychnin, quinin, iron, small doses 
of arsenic, and phosphorus may be used. Preparations of malt and 
cod-liver oil are often indicated. Stelwagon has found general galvan¬ 
ization of value in one or two patients. In exceptional cases arsenic 


252 


DISEASES OF THE SKIN. 


in full doses acts almost as a specific; it is of most value in vesicular 
and bullous eruptions. It should be remembered that when arsenic is 
not suited to a given case large doses of the drug may do much harm. 

Other existing disturbances of the general economy due to rheumatic 
tendencies, kidney disease, indigestion, constipation, or any other cause 
should be recognized and properly be treated. 

Locally treatment is directed to keeping the surface clean and 
aseptic, and to making the patient comfortable. Duliring recommends 
stimulating applications when they are well tolerated, but in many 
cases soothing and sedative preparations are necessary. Among the 
stimulating applications which have proved of value may be mentioned 
lotions and oils containing tar, carbolic acid (1 to 20 per cent.), ich- 
thyol (2 to 10 per cent.), and thymol (1 to 5 grains to the ounce). 
Stelwagon highly recommends liquor carbonis detergens in strength 
varying from 1 to 10 of water up to the pure solution. Duhring found 
sulphur ointment (2 drachms of sulphur to the ounce) of great value 
in cases in which there were vesicular, pustular, and bullous lesions. 
This ointment should be rubbed in vigorously, but should be tried on 
a small surface at a time for fear of exciting too much irritation. 

In most cases a soothing treatment is demanded by means of alkaline, 
bran, or other demulcent baths, followed by some of the dusting- 
powders or the lotions advised for use in the acute stages of eczema. 
Ointments are not indicated, as a rule, but in a few cases the diachylon 
ointment of Hebra, the Lassar paste, zinc, mercurial, and other pastes 
and ointments have been used to advantage. For relief from itching 
camphor and chloral (1 to 5 per cent.) in oils or ointments may be 
employed. Many patients are treated with very great comfort to the 
end in the continuous warm-water bath. 

The prognosis is always doubtful, and is often grave. It is not 
certain that the disease is ever completely relieved, though temporary 
recovery from repeated outbreaks is common. 


POMPHOLYX. 

(Gr. 7 TOfi<j>6hv%, a bubble.) 

(Cheiro-pompholyx, Dysidrosis.) 

Pompholyx is an affection of the hands and the feet chiefly, and characterized by the 
occurrence in these regions of vesicular and bullous lesions of persistent type. 

The disorder indicated by the above title has been the occasion of 
no little medical controversy. Observers are still not agreed as to its 
nature and identity. In the latest edition of his valuable work Kaposi 
asserts that the symptoms are those simply of acute eczema. Tilbury 
Fox, Hutchinson, Robinson, and others have made exceedingly careful 
studies of the disease. The paragraphs in this treatise devoted to 
Dysidrosis are intended to call attention to the disease as it occurs in 
connection with the affections of the sweat- or coil-glands. 

Symptoms. The disease affects simultaneously and, as a rule, svm- 


INFLAMMA TIONS. 


253 


metrically the hands and the feet; if either organs are spared, it is 
commonly the two feet. One side may be worse than the other. The 
eruption is preceded or is accompanied by a burning or a tingling pain, 
and is characterized by the appearance on the dorsum or the sides 
of the fingers or over the palms and soles or over the whole hand or 
foot, of deeply set, single or numerous, grouped or confluent vesicles, 
or of vesico-bullse. According to Fox, in the earliest stages of the 
vesicles, annular collections of fluid may be seen about the sweat-pores. 
The appearance of well-developed lesions is compared with that of 
boiled sago-grains imbedded within the skin. When the bullae attain 
extreme development the distended lesions, as large as pigeon’s eggs, 
project from the skin, these lesions being irregularly outlined and 
containing a neutral or an alkaline fluid, translucent or turbid, and 
seated on an cedematous, often exquisitely painful and sensitive skin. 
They are said not to rupture spontaneously, but to undergo absorption 
in a fortnight or more, with exfoliation of the loosened epidermis, but 
there are well-marked exceptions to the rule. Beneath the purposely 
ruptured bullse is a new-formed and reddened or exfoliating and sodden 
(which under favorable circumstances becomes later a sound) epidermis. 
The hyperidrosis mentioned by some authors may or may not be a 
prominent feature in the case of affected patients before and during the 
occurrence of the disease. There may be recurrent attacks in consec¬ 
utive seasons, and also recrudescence of the disease in the affected. It 
occurs in both sexes, but apparently more often in women in England; 
in America it is believed that more male patients have suffered. The 
ages of the latter are from those of childhood to those of middle life; 
one well-marked case occurred in a man of sixty. The sufferers, with 
but few exceptions, are in poor health, are broken down from nervous 
overstrain, and are neurasthenic rather than cachectic. 

Pathology. The differences among observers respecting the character 
of the disease depend upon whether the view is taken with Fox, 
Crocker, and others, that the vesicles lie directly connected with or in 
the line of the sweat-duct; or whether, with Hutchinson, Robinson, 
and others, no connection with the coil glands is recognized, the vesi¬ 
cles lying in the superior portions of the rete over the papillae and not 
the rete pegs which pass below to meet the duct of the coil-gland. 
Crocker, however, found some lesions in both situations. The disease 
occurs most frequently in persons who are worried or nervously 
depressed, and is probably a neurosis. 

Diagnosis. Pompholyx is to be differentiated from eczema which it 
certainly does not resemble. The tendency of the vesicles to persist, 
and after intentional rupture, not to furnish from the former floor a 
serous exudate, is strikingly different from the course of eczema. Again, 
there is seldom, if ever, in well-marked pompholyx, a tendency to 
change in type from a serous to a pustular exudation. Lastly, eczema 
of the palms and the soles is almost invariably of erythematous type. 

Treatment. The internal treatment of these cases is of importance. 
Patients require the best climatic and hygienic environment and mental 
distraction. In the way of medicaments, quinin, nux vomica, iron, 
the mineral acids, cod-liver oil, matzool, and kumyss may be needed. 


254 


DISEASES OF THE SKIN. 


The local treatment is by employment of the Lassar paste covered with 
boric or salicylated powders; or by the application of strips of muslin 
spread with lead or with zinc salves. 


PSORIASIS. 

(Gr. ipopa, the itch.) 

(Lepra, Aephos, Psora. Ger., Schuppenflechte.) 

Psoriasis is a cutaneous disease, acute, or, more usually, chronic in course, and char¬ 
acterized by masses of whitish, lustrous, adherent scales, in pin-head-sized agglom¬ 
erations upon the surface of the skin, or in larger disks resting upon circumscribed, 
usually circular and reddened patches of epidermis, which are readily made to 
bleed. 

Symptoms. In psoriasis the primary lesion is a punctiform macule 
of reddish-brown tint, which always at the earliest moment of observa¬ 
tion is covered with a delicate, whitish, epidermic scale. When this 
scale is removed, even by gentle scraping, one or more minute droplets 
of blood exude from the points beneath which lie the vascular papillae 
of the corium. 

The lesions of psoriasis vary so widely in size, shape, and distribu¬ 
tion that the various phases of the disease have been given descriptive 
names. These names have no pathological significance, and are used 
solely for the purpose of indicating the size, configuration, and distri¬ 
bution of the lesions. When the disease appears in the form of small 
scale-covered points it is called psoriasis punctata . Should the disease 
progress to fuller development, there form patches of larger size, always 
with a definite contour, very slightly elevated above the general level 
of the integument, and covered with whitish, mother-of-pearl-colored 
scales in abundance. When these scales are about the size of drops 
of water the disease is termed psoriasis guttata. In yet more advanced 
conditions of the disease other names are employed. Thus psoriasis 
nummularis is characterized by coin-sized patches; psoriasis circinata , 
or orbicularis , by patches where the disease is actively exhibited at the 
periphery of a circle, in the centre of which the scales have disap¬ 
peared. Psoriasis gyrata and figurata, by coalescence and extension of 
several patches, forming thus fantastic figures covered with grayish- 
white, imbricated scales; and psoriasis diffusa , by much more extended 
and uniform involvement of the skin in large areas. 

The greatest variation is exhibited in the progress of the disease, 
and to this point special attention should be directed. Thus, in a 
single individual the eruption may appear upon one or more regions of 
the body in the form of the punctate lesions described above, and 
thereafter may regularly progress through the degrees suggested by 
the list of names given, until the surface of the body is completely 
covered from the crown of the head to the soles of the feet. This 
condition is, fortunately, very rare, and, indeed, denied by some 
observers. One rarely sees a case where a few square inches of 


INF LAMM A TIONS. 


255 


sound skin cannot be discovered at some point of the body-surface. 
More often the eruption tends to remain stationary when one or an¬ 
other of the less extensively developed phases of the disease has been 
displayed. Thus, the patches may at no time be larger than the size 
of a small coin, and, though very numerous, may fail for years to ex¬ 
tend beyond such a limit. They may persist even for a longer period 
in still smaller dimensions, or, what is perhaps more common, may 
occur in guttate forms upon the chest, and in patches as large as the 
palm over the knee or the sacrum. 

The sites of preference of the disease are over the extensor surfaces 
of the extremities, especially about the elbow and the knee, where it is 
decidedly most common. After these locations should be named in 
order the region of the sacrum (where often the largest patch upon 
the body can be discovered), the upper surface of the chest, the scalp, 
the face, the belly, and the genitals, more rarely the hands and the 
feet. 

The disease is essentially chronic in its course, is never contagious, 
and the efflorescence does not usually awaken any subjective sensation. 
Its features are so pronounced in typical cases that its recognition is 
facile, after appreciating the number and distribution of the patches, 
their clean-cut outline, the unaltered integument between the lustrous 
and shining scales, and the red border of the skin which may crop out 
from beneath the squamous thatch above, or be completely hidden by 
the latter. Rarely a single isolated patch betrays the existence of the 
disorder. 

When the disease is acutely spreading over the skin-surface it has 
occasionally a different expression, which is often seen in young adults. 
The patches are perhaps as large as the section of a hen’s egg; are dark 
or lurid-red over the whole; are covered with a more uniformly con¬ 
stituted, thin, squamous film, or sheet of semi-transparent delicate 
membrane, through Avhich the red glare of the patch beneath is visi¬ 
ble. This condition may also be seen in young persons to whom 
arsenic has been administered for the relief of the disease, with the 
production of irritative effects. 

In its indolent moods the color of the patch varies somewhat with 
the hue of the patient’s complexion. Blonde women with flaxen hair 
and clear tint of the integument often exhibit singularly waxy-whitish 
patches, decidedly differing in color from those occurring upon the 
muddy and greasy integument of certain dark-skinned men. The 
scales, which are usually abundant, may adhere with considerable 
firmness to the patch, or, more frequently, may be shed freely from 
the surface, in pronounced cases powdering the clothing of the patient 
or the sheets of the bed upon which he reposes at night. 

There is never at any time in the course of the disease the appear¬ 
ance of other lesions or their sequels, such as vesicles, pustules, crusts, 
papules, tubercles, or ulcers, nor any discharge-feature. The eruption 
is dry from first to last. Exception may only be made in the case of 
patches occurring where motion of the skin produces fissure, an acci¬ 
dental and by no means characteristic complication. Exception may 
also be made of certain acute symptoms, especially developed in young 


256 


DISEASES OF THE SKIN. 


and tender skins, where considerable redness, occasionally with an 
erythematous halo, appears in and about individual patches, with the 
production of itching, heat, burning, pain, or other disagreeable sen¬ 
sations. 

The involution of the disease is evident in a gradual cessation of the 
scale-formatiou and the exhibition of a normal epidermis which pro¬ 
gressively spreads from the centre, or is at once perceptible over the 
entire surface of the patches. No cicatrization results. 

Upon the scalp plaques of well-defined contour, covered with thick 
whitish scales, may mat the hairs together, but alopecia almost never 
results. The dry condition of these scales contrasts with the greasiness 
of the crusts formed in seborrhea of the scalp. Often a fillet or band 
of diseased tissue, one or more inches in width, projects beyond the 
border-line of the scalp and forehead. When the vertex is bald from 
physiological loss of hair the patch of psoriasis usually lingers near 
the fringe of the hairs left at the sides of the head, projecting thence 
to the regions of baldness. On the face, as well as over the genitals, 
the lesions are usually both indistinct and small-sized, they being dis¬ 
played, as regards the former locality, over the cheeks, chin, and nose, 
avoiding the parts near the mucous orifices. When there is much 
vascular congestion, especially of the passive kind, the patches assume 
a violaceous or purplish tint. All forms of lesions are seen upon the 
trunk, especially over the dorsum and near the sacrum; the patches, 
in well-marked cases, encircling the body in ill-defined parallels reach¬ 
ing from the spine forward. The hands, feet, fingers, and toes are 
not often involved, and the palms and soles only so rarely invaded 
as to throw doubt upon a diagnosis based upon the existence of the 
disease solely in these regions. In severe cases the nails are second¬ 
arily attacked, being thickened, eroded in points, irregularly lami¬ 
nated, rigid, and becoming brittle, and yellowish-white or dirty whitish 
in color. 

The amount of scaling varies greatly in different persons and in the 
same individual; sometimes the scales are abundant and thickly heaped 
up over even small areas; sometimes they are sparse over large areas. 
In acute febrile and other intercurrent diseases the disorder may fade 
or disappear. Where the epidermis is thin, the scaling is less; there¬ 
fore, over flexor surfaces, near the mucous orifices, and on the back 
of the hands, the scaling is less than over extensor surfaces, in regions 
remote from the mucous orifices, and on the palms and soles. It is 
also less in youth than in advanced years. The disease may for years 
be limited to two or three continuously existing patches, or, what is 
far more common, may recur at irregular intervals and under varying 
circumstances. As a rule, it is worse in winter and in cold climates, 
though patients may demonstrate the reverse of this. 

The scales may display, instead of a lustrous white, a deep yellowish 
shade, and, instead of being imbricated, may form a thin, continuous 
sheet of exfoliated epidermis. When the disease is disappearing the 
scales fall, leaving a pigmented or slightly discolored patch of integu¬ 
ment. 

A rare ultimate termination of the disease is the formation of ver- 


INF LAMM A TIONS. 


257 


rucous growths in the psoriatic patches, which later become epithelio- 
matous. 1 At times the eruption is the source of excessive annoyance, 
being the seat of intense pruritic and burning sensations of a persistent 
type. 

There can be no question that intermediate forms between eczema 
and psoriasis occur, in which forms it is difficult to determine whether 
the two disorders coexist, or the one has assumed the features of the 
other. In these cases there are itching and infiltration of the skin, with 
vesicular and other lesions foreign to psoriasis, and a catarrhal dis¬ 
charge. 

Psoriasis is not known to affect the mucous surfaces. The lesions of 
so-called “psoriasis linguae 79 are those of “leukoplakia buccalis," 
of /* smokers' patches," of syphilitic disease of the mouth, or flat 
epitheliomata. 

Etiology. The causes of psoriasis are not known. As no external 
or internal factors can be demonstrated to be effective in its production, 
it is safest to conclude that these unrecognized sources of the affection 
are limited to the skin itself. The disease is neither contagious nor 
hereditary, nor limited to either sex, occupation, or social condition; it 
bears no relation whatever to syphilis, eczema, gout, rheumatism, 
struma, or dyspepsia; it appears in feeble and delicate individuals as 
in the most superb specimens of manly vigor and womanly beauty, 
and though not occurring in infancy, yet it usually first appears in early 
life. Kaposi reports a single case in which the eruption appeared in the 
eighth month, and Elliot a case of first appearance at the eighteenth 
month of life. Under these circumstances the question arises: Is this 
affection of the integument, when uncomplicated by the disagreeable 
symptoms named above, a disease or a deformity ? Certainly in a 
very large number of individuals, displaying through life unchanging 
patches where the characteristic symptoms are the same year after 
year, the ailment would seem more properly to be classed with the 
deformities than with the diseases of the skin. In point of frequency 
the eruption ranks next after eczema. 

No child was ever born psoriatic, yet believers in the possibility of 
the transmission of the disease by inheritance are numerous, and some 
of them are careful observers. Robinson goes so far as to say that in 
the “ majority" of all cases there is an inherited predisposition to the 
disease. Others conclude it to be an inherited or transmitted form of 
syphilis, struma, tuberculosis, rheumatism, or gout. Weyl thinks that 
inheritance may possibly be the sole cause. Bazin admits the existence 
of both an herpetic and an arthritic psoriasis. 

Bearing in mind, on the one hand, the relative frequency of psoriasis, 
and, on the other hand, the strict tests which should be applied in 
order to prove that a disease is actually transmitted by heredity, we 
find that the doctrine of heredity in psoriasis fails of establishment. 
It is putting a low estimate on the actual figures to state positively 
that there are more than one thousand psoriatic patients in every large 
country, no one of whose ancestors, so far as known, ever had psoriasis, 


1 See Dr. J. C. White’s paper, American Journal of the Medical Sciences, 1885. 

17 


258 


DISEASES OF THE SKIN. 


syphilis, or rheumatism. They furnish too large a body of evidence 
to be either ignored or set aside with a word. Thousands of their 
children are living to-day free for years from any evidences of disease; 
they, too, call for further proof on this point. 

It has long been known that in psoriatic subjects lesions may artifi¬ 
cially be developed in the lines of mechanical irritation. In this way, 
figures in the shape of anchors, crosses, hearts, etc., have been pro¬ 
duced on the skin of psoriatic patients, one of whom has been ingeni¬ 
ously photographed by Fox, of New York. 1 The disease has also 
been attributed to vaso-motor neurosis, to fright, to shock, and to 
neuralgias. 

The disorder is rather more common in male than in female patients, 
and it appears to be rare in the negro races. According to Greenough’s 
statistics, it represents about 2J per cent, of all cases of cutaneous 
disease. It has followed vaccination, scarlet fever, and other diseases. 

Gowers alone reports the artificial production of psoriasis by the 
internal administration of the biborate of sodium. Allusion has here¬ 
tofore been made to this circumstance in the chapter on Dermatitis 
Medicamentosa (g. V.). Further evidence would be required to estab¬ 
lish the fact that these results differed to any appreciable extent from 
those recognized in any squamous dermatitis produced by an ingested 
drug. 

In some cases the disorder is due to the exclusion of sunlight from 
those portions of the body covered with the clothing and the hair. 
Certain it is that only in extreme cases is the face attacked at a dis¬ 
tance from the line of the hairs upon the brow and bearded region 
(sides, of the nose, cheeks, temples). It is likewise true that after 
exposure to abundant sunlight of these parts, not only when patients 
are intentionally treated by such exposures of the nude body to light 
in hospitals and in private practice, but in occupations which neces¬ 
sitate the same, beneficial results are often well marked. 

Pathology. The observations of Wertheim, Neumann, Auspitz, 
Kaposi, and Robinson, of New York, are substantially in accord 
respecting the general character of the changes occurring in the course 
of the disease, though they differ upon the question whether it depends 
upon an inflammatory or a purely hyperplastic process. So far as this 
problem is illuminated by clinical facts, it would seem clear that both 
views are correct, the disease being at times unquestionably the result 
of a circumscribed inflammation, at other times being associated with 
a simple overgrowth of the elements of the epidermis, and again at 
times with an inflammation which the hyperplasia has awakened. 
There is always abundant development of epithelia in the rete, and, 
in recently formed patches, distention of blood- and lymph-vessels 
in the papillary layer of the corium beneath. In older plaques the 
rete either dips downward to an unusual extent between the papillae, 
or the latter push upward in the manner of wart-like prolongations. 
It is reasonable to conclude that at times both hypertrophies concur. 
The corium is thickened later by an increase of its elements which may 

1 In his admirable Photographic Illustrations of Cutaneous Diseases. New York. 


INFLAMMA TIONS. 


259 


involve its entire width as far as the connective tissue. In the older 
plaques, also, the connective-tissue elements are often separated by a 
slight serous infiltration. Hyper-pigmentation is also noted. The 
external root-sheath of the hairs in direct connection with the rete 
participates in the same process, thus explaining the defluvium capillitii 
of certain cases, and the resulting transient or permanent baldness. 
The sebaceous glands are secondarily involved in the scalp only. 


Fig. 48. 



Vertical section of skin from a patch of psoriasis of long standing: MP, Malpighian 
prolongation ; C, corium; L, leucocytes. (After Jamieson.) 

Lang, 1 of Innsbruck, attracted notice by his alleged discovery of 
certain fungous elements in psoriasis that he claims to be the cause of 
the disease. These fungi he finds in the whitish pellicle beneath the 
superficial squamous layer, to which Bulkley had already called atten¬ 
tion. After stripping the pellicle or a part of it from the surface, and 
subjecting it to the action of a 5 per ceut. solution of caustic potash, 
the epithelium becomes translucent, and upon and beneath the epithe¬ 
lium double-contoured and highly refractive spores become visible. 
Lang considers this fungus to be of the lowest species, different from 
any previously recognized upon the skin, and he terms it u epidermo- 
phyton.” In his treatment of psoriasis this author proceeds upon the 


i Viert. f. Derm. u. Sypb., 1878. 









260 


DISEASES OF THE SKIN. 


principles which govern the management of the other dermato-mycoses. 
He considers that the value of the remedies hitherto found most useful 
in the disease, such as tar, carbolic acid, chrysarobin, and the mercu¬ 
rials, owe their efficacy to their destructive action upon the fungus. 
He has used with advantage a topical application of rufigallic acid in 
a salve, one part in ten. 

Weyl, who believes that psoriasis is due to u an inherited weakness 
of the nervous centres,” has seen Lang’s u brood-cells,” and he 
regards them as u myelin-like exudations;” but this position is dis¬ 
puted by both Wolff 1 and Eklund, 2 who confirm Lang’s observations 
and who believe the disease to be of parasitic origin. They explain 
the artificial production of psoriatic patches in the psoriatic skin by 
supposing spores to have been deposited beneath the skin, and not 
previously awakened to activity in the sites of such experiments. 

Lassar 3 succeeded in producing a disease of the skin in rabbits by 
rubbing into various portions of their bodies scales, blood, and lymph 
removed from psoriatic patches of a male patient. The disease thus 
induced is capable of transmission to other animals. Campana, Tom- 
masoli, and other Italian observers have repeated these experiments, 
with the result of reaching the conclusion that psoriasis is produced by 
a parasite as yet unrecognized. 

Diagnosis. The recognition of a pronounced case of psoriasis is 
made with ease, and often by those unskilled in cutaneous disease. 
As usual, it is the atypical forms of the eruption that occasion doubt. 
Psoriasis is to be distinguished from : 

Eczema. Eczema and psoriasis differ in a striking manner with 
respect to their sites of predilection, and their extension from such 
sites in progressive cases. Eczema, from the head to the toes, elects 
the anterior surface of the body, the neighborhood of the mucous out¬ 
lets, the flexor faces of the joints and limbs, the crevices, folds, pockets, 
depressions, and protected angles of the skin. Psoriasis elects the 
posterior surfaces of the body, avoids the vicinity of the mucous out¬ 
lets, spreads abundantly over the extensor aspect of the joints and 
extremities, and enjoys the regions of pressure and friction, as the 
skin over the patella and the olecranon process of the ulna. Psoriasis, 
covering the vertex and scalp, lingers at the brow, where its scaly 
thatch stretches from side to side close to the line of the hairs, and 
creeps more indistinctly down the face on either side in front of the 
ear, reluctant to spread over the cheeks, nose, and lips. Eczema easily 
escapes from the scalp to the nose, lips, or chin, or lurks in the folds 
of the pinna of the ear. Psoriasis will cover the back and reach for¬ 
ward in front by almost symmetrically disposed parallels in the direc¬ 
tion of the ribs, while eczema sweeps between and beneath the breasts 
or around the nipple. Psoriasis may cover the belly and spare the 
navel and pubes, sites where eczema may originate. As before stated, 
the largest patch of psoriasis on the body will often be discovered over 
the sacrum, while eczema creeps upward with a diminishing vigor from 


1 Viert. f. Derm. u. Syph., 1884. 

3 Deutsch. med. Zeitg., 1885, No. 93. 


2 Annal. de Derm, et de Syph., 1885. 


INF LAMM A TIONS. 


261 


the anus between the clefts of the nates. Psoriasis often spares the 
hands and the feet, which eczema punishes. 

In individual patches eczema will be recognized by its severe itch- 
ing; by the scratching it excites; by the history of moisture, discharge, 
and crusting; by its ill-defined outline; by its asymmetrical disposition, 
except upon the similarly irritated hands and feet; and by the fewer, 
more yellowish, smaller, and less lustrous scales which characterize its 
squamous varieties. 

Favus of the scalp might be mistaken for psoriasis of the same 
region, but the occurrence of sulphur-colored, cup-shaped crusts, the 
existence of the parasite, the lustreless and brittle condition of the 
hairs, and a possible history of contagion, will insure identification of 
favus. In psoriasis, too, the hairs are usually firmly attached in 
their follicles, while they are loosened in favus. 

Lichen Ruber Acuminatus, though a very much rarer disease 
than psoriasis, must in cases be carefully recognized as distinct from 
the latter. In lichen ruber the lesions are papular, distinct, are cov¬ 
ered by few scales, these being yellowish in color, and never lustrous. 
There is always a constitutional impairment of health, and, when the 
whole epidermis begins to break up in scales, a coudition of well- 
marked marasmus. When scratched, the patches of the disease do 
not bleed. Finally, lichen ruber tends to a fatal termination. 

Lichen Ruber Planus. In this disorder the scales are at the 
outset attached to the apices of minute polygonal papules, which are 
situated on the flexor rather than on the extensor aspects of the extrem¬ 
ities where psoriasis is more abundant. The patches in well-marked 
cases of lichen planus have a characteristic crimson-red or a purplish 
hue, rarely lacking and never perfectly seen in any case of psoriasis. 
The scales, further, of lichen planus are of a very characteristic silvery 
whiteness which is never perfectly seen in psoriasis, though imitated 
by the yellowish-white or pearl-white hues of the latter. Lichen 
planus never appears in oval or roundish patches, but is peculiar 
among all dermatoses in its angular, linear, and even stellate arrange¬ 
ments. 

Lupus Erythematosus. In any doubtful case in which cicatricial 
tissue is discovered in the site of a patch where the disease has existed 
the diagnosis is clear, since psoriasis never leaves a scar. Lupus pre¬ 
fers the nose, the cheeks, and other parts of the face commonly spared 
by psoriasis, unless the eruption be very abundant elsewhere. The 
scales of lupus are scanty, firmly adherent, yellowish, and attached to 
the orifices of the ducts of the sebaceous follicles; those of psoriasis are 
abundant, lustrous, and shed freely from the surface. Lupus is almost 
never, like psoriasis, a generalized eruption, and is always much more 
chronic in course. There is a bluish and violaceous tint to the reddish 
patch of lupus erythematosus, especially as it occurs upon the face, 
while the highly colored patches of psoriasis are rarely facial, being 


262 


DISEASES OF THE SKIN. 


more commonly seen on the trunk and extremities, and the out¬ 
cropping disks on the face are the least colored of any on the body. 

Pityriasis Maculata et Circinata. In this disease the patches 
are more oval than circular and the scales are much finer than those in 
psoriasis; it is, moreover, much more rapid in its career and does not 
recur. AVhen the branny scales are removed the surface beneath does 
not bleed. The centre of the patch is usually tawny or salmon-colored. 
The thoracic surface may also be exclusively involved. 

Pityriasis Rubra. If psoriasis be in any case generalized, its 
distinction from pityriasis rubra would be difficult, if not impossible, 
on the basis of our present knowledge. Indeed, any such distinction 
would have but little practical value. A few typical isolated patches 
of a psoriatic character would point to the origin of the disease in any 
doubtful case. 

Seborrhea. This disease could only be confounded with psoriasis 
of the scalp; but the last-named affection is, in the vast majority of 
cases, exhibited also in patches upon other portions of the body where 
seborrhea is never seen. Seborrhea of the scalp also occurs in usually 
diffuse forms, the surface beneath the crusts being rather anemic and 
pallid in appearance, not bleeding readily, as in psoriasis. The crusts, 
too, in seborrhea, are distinctly fatty and greasy when rolled between 
the fingers, and have a dirty yellowish hue, rarely recognized in the 
whitish scales of psoriasis. In psoriasis the hairs are not loosened as 
in seborrhea. Lastly, seborrheic crusts may fringe slightly the line of 
the hairs at the brow, but they rarely form a band an inch or more in 
width, like a frontlet covering the upper half of the forehead, a not 
uncommon development in psoriasis. 

Syphilis. Psoriasis does in many cases greatly resemble the squa¬ 
mous and papulo-squamous syphilides. The necessity for a clear 
recognition of either disease occurring in suggestive patches is often 
of the highest importance. 

In syphilis the greatest aid will be obtained by a history in both 
sexes, of infection, adenopathy, and mucous patches; and in women 
of abortions, miscarriages, or stillbirths. Psoriasis is a singularly 
uniform disease; syphilis is decidedly multiform in its manifestations. 
Syphilitic patches are less symmetrical, more elevated at the edge, 
and the scales with which they are covered are fewer, smaller, and 
dirty whitish, rather than lustrous, in color. In syphilis the eruption 
is less generalized, and shares with other syphilodermata the brown¬ 
ish and purplish hues of the skin beneath, lacking the vivid redness 
and pinkish-red of many non-syphilitic lesions. The scales of many 
of the syphilides which resemble psoriasis partake of the character of 
crusts, being agglutinated by pathological exudations from the patch; 
they are rarely so exclusively squamous as in psoriasis. In syphilis 
the tendency of the patch is to exhibit an affected surface somewhat 
beyond the line of the scales; in psoriasis the scales more frequently reach 


INFLAMMA TIONS. 


263 


beyond the border of the affected epidermis beneath. The squamous 
syphiloderm of the palms and soles often occurs only in these localities. 
Psoriasis is extremely rare in such situations, and is almost never lim¬ 
ited to these regions exclusively. A psoriasiform circlet limited to the 
region of the mouth, nose, or chin will generally prove to be syphilitic. 
The disease which has for a long time persisted in the production of 
squamous patches can generally be demonstrated to be psoriasis, as 
syphilis changes its type in the course of months. 

Tinea Circinata. In tinea circinata the discovery of the para¬ 
site, a history of contagion, and the frequent limitation of the disease 
to a single patch (a feature exceedingly rare in psoriasis), will usually 
suffice to establish a diagnosis. In ringworm of the body the scales 
are bran-like, and are more abundantly formed at the margin of the 
patch where the fungus is luxuriant; while in psoriasis, the scaliness is 
usually equally pronounced over the entire area of an invaded patch, 
unless the disease is in process of involution. The occasional occur¬ 
rence of vesicles and vesico-papules at the peripheral border of the 
patch in ringworm is never observed in psoriasis. Ringworm is never 
generalized symmetrically; and upon the scalp or beard the discovery 
of brittle and broken-off hairs should always suggest examination for 
the parasite. 

Treatment . The treatment for the relief of psoriasis must necessarily 
be limited to the removal of its objective features. This treatment 
may be internal, with a view to the indirect action of the drug selected 
upon the skin; or topical, with a view merely to the reproduction of 
a sound epidermis in the patches of disease. 

Arsenic enjoys the highest rank in the internal treatment of psoriasis. 
What it is capable of accomplishing in other cases it can with best 
effect accomplish here. Whatever failures must be charged to its 
account in the attempt to relieve other cutaneous eruptions cannot 
safely be ignored in psoriasis. 

The facts are as follows: arsenic administered internally is assuredly 
capable of relieving a certain proportion of cases of psoriasis. Given 
improperly in any case, it may be either powerless or manifestly be 
injurious. In a certain proportion of patients, most carefully selected 
as fit subjects for its therapeutic action, arsenic will prove utterly 
valueless in the most skilled hands. It cannot be demonstrated to 
possess the power to prevent recurrences of psoriasis, yet the latter 
must be recognized as a disease exceedingly liable to recur. Unfor¬ 
tunately, the proportion of cases in which arsenic will and in which 
it will not exhibit its happiest effects is not known. 

The following rules for the administration of arsenic are in general 
to be observed. It should be given with or immediately after the 
ingestion of food, so that it may be commingled with edible substances 
in the stomach. It should be given at first in small doses, which are 
to be cautiously increased. The possibility of the production of toxic 
effects should be remembered, and on their appearance the remedy is to 
be given in a smaller dose, and not completely discontinued unless 


264 


DISEASES OF THE SKIN. 


such a course be imperative. If its administration be once determined 
upon, the arsenic should not hastily be withdrawn and auother remedy 
substituted, but persistence for months should be enforced if no serious 
objection exist, lest the time be wasted which has been already expended 
in the effort to relieve the disease. 

Arsenic is unsuited for all cases of psoriasis occurring with rather 
acute symptoms, such as subjective sensations aud unusually vivid 
redness of the patches. It should not be given when the disease is in 
process of evolution, and, therefore, not in psoriasis punctata and 
guttata, unless the lesions have long been limited to patches of the 
sizes to which these names are given. For the same reasons it is often 
objectionable in the psoriasis of the young, for, though the drug is 
usually rather well tolerated in early periods of life, it is, unfortunately, 
in the young where the disease is also most often encountered in its 
progressive stages. 

The remedial effect of arsenic, when that is obtained, seems to 
depend upon the impression it exerts upon the rete, especially that 
part of it which lies in connection with the derma. When the metal 
is injected subcutaneously its first effects, according to Jamieson and 
Nunn, 1 are indicated by the appearance of a faint narrow band along 
the base of the columnar epithelia immediately next the corium. This 
band is due to a softening of the protoplasm which separates the epi¬ 
dermal from the dermal elements. Subsequently the remoter epithelia 
are involved, the protoplasmic threads becoming obscure, the char¬ 
acteristic arrangement of the epithelia becoming less evident, and the 
natural features of the rete distorted, so that it remains attached to the 
derma by tags and by the prolongations which it sends down to the 
cutaneous glands. Jamieson suggests that arsenic stimulates the 
epithelia to exhaustion, the layer which lies next the bloodvessels 
containing the metal first appreciating its effects. 

The preparation usually employed is Fowler’s solution, the exhi¬ 
bition of which should always be begun in doses from J minim (0.033) 
to 3 minims (0.20), this amount to be contained iu a solution of fixed 
and relatively large dose, such as a teaspoonful of infusion of pep¬ 
permint, wine of iron, dilute syrup of gentian or of orange blossoms, 
or compound tincture of cardamom with water. When only remedial 
effects are obtained, such as diminution of the scaliness, the dose may 
steadily be continued without change for long periods of time, and 
usually with advantage for some time after the symptoms of the disease 
have entirely disappeared. When, without the production of toxic 
effects, the eruption seems quite unaffected by treatment, the arsenic 
may very carefully and always under the direction of the physician 
only, be pushed until 20 and even 30 drops of Fowler’s solution 
(the latter equivalent to j- grain (0.22) of arsenic) are administered at 
a dose. 

The constitution of the Asiatic pill has been given in the chapter 
on General Therapeutics. This pill is less likely to be as well toler¬ 
ated by the stomach as Fowler’s solution, but cases are on record in 

1879 Se p 627 Papei by Jamieson on the Histology of Psoriasis, Edinburgh Medical Journal, January, 


INF LAMM A TIONS. 


265 


which the psoriasis which proved rebellious under the administration 
of the liquor arsenicalis, Donovan’s solution, and other internal reme¬ 
dies, yielded to the influence of arsenious acid in pilularform. Hebra 
has given two thousand Asiatic pills to a single patient before the dis¬ 
ease disappeared; and in no instance did he see any ill-effects produced. 

With regard to the vulgar opinion respecting the arsenic-habit, 
which a long familiarity with this dosage has been supposed to beget, 
it is curious that one never encounters such an instance in a psoriatic 
subject consuming arsenic. Patients who for several consecutive years 
have, without interruption, pursued an arsenical course, thus barely 
succeeding in keeping their cutaneous ailment out of sight, will in 
many cases affirm that, apart from any trifling and accidental toxic 
symptoms, and those evident in the course of the eruption, they would 
not be sensible of the fact that they had taken the drug. 

With an enlarging experience, one views with greater distrust each 
year the benefits to be derived from arsenic in any untried case of 
psoriasis. The great possibilities of its failure, of the repeated recur¬ 
rence of the eruption, of the necessity of continuing the medication 
for one or two years, and, after that period of time, of witnessing a 
generalized development of the disease to an extent quite equal to that 
exhibited at the outset —all these considerations should certainly have 
some weight in the mind of an ordinarily prudent man. Yet, in a 
minority of cases in which, under a judiciously directed arsenical 
course, the eruption slowly disappears and fails to recur, the value of 
the treatment is incontestable. 

The course which, under the circumstances, seems preferable, is as 
follows: Instead of resorting first to the arsenical dose and afterward 
to other measures, the order should be reversed. That case of psoriasis 
which fails to respond to other treatment may finally be subjected to 
the influence of arsenic. He who, having vainly tried other approved 
measures, essays at last the virtues of this medicament, ought certainly 
to exhibit no impatience while testing his case with it. He should be 
willing to try it fully and fairly, and of all men be least ready to 
exchange it for a less valuable substitute. No reference is here made 
to the effect of conjoined internal medication with arsenic and external 
treatment by topical applications. However desirable it may be in 
the management of any individual case to arrive at the desired end 
by the speediest method, it is evidently needful, in order to assign to 
arsenic its exact therapeutical value, to understand what arsenic can 
accomplish unaided by topical measures. 

Crocker has lately advised the use of salicylate of sodium and salicin 
in all forms of psoriasis, but especially during periods of active devel¬ 
opment of the disease, when arsenic usually does harm. Haslund 
recommends the iodid of potassium, increased from the smaller to the 
largest tolerated doses. As many as six hundred grains of the iodid 
have been administered by this method per diem; it is of occasional 
service. The wine of antimony in 5 to 10 minim doses; chrysarobin, 
J grain, rubbed up with sugar of milk, three times daily; bromid of 
potassium and the iodid of sodium have also been administered in 
some cases with reported success. 


266 


DISEASES OF THE SKIN. 


As to the other remedies employed internally for the relief of the 
malady, a very fair estimate of their value can be made by remember¬ 
ing that arsenic is superior to them all. If arsenic fail so frequently, 
what remains to be said of the other articles on the list? Phosphorus, 
tar, copaiba, cantharides, colchicum, and pilocarpin have at times a 
feeble transitory influence over the patches of the eruption, but their 
employment will disappoint far more often than satisfy. Iron, quinin, 
cod-liver oil, and the salts of the alkalies, will meet important indica¬ 
tions in the treatment of certain classes of patients, but such patients 
are in the minority, as the eruption is often seen in perfectly vigorous 
and otherwise healthy subjects. 

After the use of any one of these remedies, it is rare to recognize 
any decided effect upon the cutaneous symptoms, even when patients 
in whose case they were indicated improve under their use. 

The same statement in general may be made of the use of dietary 
articles in psoriasis. As no ingesta save the substances already named 
are recognized as influencing the eruption to any perceptible degree, 
the diet suitable for a patient may in brief be described as that which 
is both wholesome and nutritious. 

Most authors agree upon the value of a greatly restricted diet. 
Acids, alcohol, and fatty substances should be excluded. Meat should 
sparingly be supplied; cooked vegetables and fruits may freely be 
eaten. Coffee, tea, and tobacco should in general be interdicted. 

Passavant, of Frankfort, on the contrary, claims to have cured 
himself and others by an exclusive diet of meat. 

The arseniate of sodium in pill-form and arseniate of iron have been 
recommended by Biell. Lipp injected arsenious acid subcutaneously. 
Robinson advises liquor potassae, citrate or acetate of potassium, or 
bicarbonate of sodium in plethoric and rheumatic patients. In the 
gouty state with excess of urates in the urine, he advises: 


•Potass, acetat., 

Al; 

32 

Spts. aether, nit., 

f|ss; 

16 

Yin. colchici, 

f 3 ij ; 

8 

Syr. aurantii, 

f 3jss; 

48 


Sig.—A dessertspoonful three times daily in water after meals. 

The influence of climate in inveterate psoriasis should never be 
ignored. Many patients who suffer from repeated relapses of the 
disease are worse in winter, and are either better or entirely free from 
the eruption in summer. Therefore, in a mild climate, where the 
temperature is uniformly registered at or near a point of maximum 
comfort for the skin, the disease will be both infrequent and less severe. 

McCall Anderson believes that sea-air and sea-water are generally 
prejudicial to psoriatic patients, but this statement is disproved in the 
case of hundreds who have removed from an interior climate to the 
seashore, solely with a view to the benefit to be thus received. 

The external or local treatment of psoriasis requires patience, care, 
and a certain degree of skill. Properly conducted, its results are 
reasonably satisfactory in a large majority of cases. 

The first indication to be met is the complete removal of the 
epidermic scales from the patches, which removal is accomplished in 



INFLAMMA TIONS. 


267 


various ways. It is preferable to secure first their maceration in some 
fatty substance, such as one of the oils, or glycerin, or vaselin, after 
which they may be washed off by the aid of soap and water, the 
patient being given a general bath if the eruption be extensive. If 
it be localized, these oily or fatty substances may be spread upon pieces 
of lint or cotton, and thus be retained in contact with the skin by a 
bandage. The scales may also speedily be removed with the dermal 
curette, if they occur in few patches, or if the patches are to be found 
in totality or in part upon some portion of the body where the disfig¬ 
urement demands special attention, as upon the forehead and the cheeks. 
The squamous masses are also removable by water alone, as after 
maceration of the skin in a bath, or after a profuse diaphoresis, or 
even after moderate exudation of sweat, if evaporation of the latter be 
prevented by covering the affected part with oiled silk or with rubber 
cloth. Usually there is no difficulty in removing these scales, patients 
often declaring to their physicians that they can themselves cleanse the 
surface. They ask to be shown how to prevent the recurrence of the 
desquamation. 

Baths play an important part in the subsequent treatment of the 
disease. They may be employed, as by Hebra, so that the patient 
remains in the water for from four to eight hours in the day; or be 
medicated by the addition of sulphur, tar, or other substances, so as 
to combine a medicative with a macerative effect. In private practice 
these baths are much less available than in hospitals. When the erup¬ 
tion is generalized and an excessive macerative effect is desired, an 
undershirt and drawers, made of soft rubber cloth, may be worn by 
the patient for several hours of the day. The sweating is often pro¬ 
fuse, and is debilitating to such an extent that the psoriatic skin will 
rarely tolerate the treatment for an entire day, or even for that part 
of the day in which active labor is performed By this sweating 
alone it will at times be found possible to secure complete disappear¬ 
ance of the patches. 

In other more obstinate cases, or in those where for any reason vig¬ 
orous treatment is indicated, as upon the scalp and face, sapo viridis 
may be employed with advantage in the soap-and-water treatment. 
The spiritus saponis kalinus, 2 ounces (64.) of the soap to 1 ounce 
(32.) of alcohol, may be briskly rubbed over the patches by the aid of 
a piece of flannel or a sponge, and then immediately be washed off 
with the oil and scales in a surplus of hot water, or be left for a time 
in contact with the part. Hebra and Kaposi employ a species of 
soap-paste, made by rubbing into each patch a small quantity of 
green soap to which a little water is added until the proper con¬ 
sistency is obtained. These inunctions are repeated twice daily for 
six days. The epidermis becomes then brownish-colored, and in three 
or four days afterward it exfoliates in lamellae; then a general bath 
cleanses the surface. In the French hospitals a somewhat speedier 
method is pursued. On the evening of the first day the patient is 
anointed with the green soap which he retains upon the skin during 
the night. In the morning he takes an alkalin bath, and immediately 
after is thoroughly anointed with lard. This course is repeated on the 


268 


DISEASES OF TIIE SKIN. 


second and third days, after which the patient is usually ready for any 
topical medication of the diseased parts. 

For the yet more obstinate cases in which exfoliation of the epi¬ 
dermis is not readily induced more energetic measures have been 
adopted, such as the local use of salicylic acid in alcohol, 1 drachm 
(4.) to 4 ounces (128.), caustic acid and alkalies, scrubbing the patches 
with nail-brushes, floor brushes, etc., and the use of clean, white sand. 

Once ready for topical medication, the patches may first be sub¬ 
jected to the local action of tar, a remedy which has enjoyed the highest 
reputation for the relief of the disease. It will, however, accomplish 
the result desired, only when so applied that it is well tolerated by the 
skin. In very young patients, as also in those whose skins are tender 
and irritable, or those suffering from any of the acute phases of the 
disease, it may prove decidedly injurious by aggravating the latter. 
The rule should be always to employ it at first tentatively over a rela¬ 
tively small portion of the affected surface, upon which the medica¬ 
ment should remain for several hours, as tar will not in all cases 
promptly produce its injurious effects. These effects are, subjectively, 
a sense of heat and pain, and, objectively, heat to the touch, redness, 
and tumefaction of the part. Often black puncta are visible when the 
tar is lodged in the orifices of the cutaneous follicles, simulating thus 
the u black head” of the comedo, a condition termed by Hebra “ tar- 
acne.” 

Pix liquida, oil of cade, or preferably oleum rusci may be em¬ 
ployed in the form of a salve, 1 drachm (4.) of either to the ounce 
(32.) of lard or other fatty basis (lanolin, vaselin, etc.). A thin stratum 
of this ointment several times in the day or merely at night may be 
painted over or well rubbed into a patch denuded of scales. In Vienna 
a still more energetic effect is secured by using soft soap freely over 
the patches while the patient is in the bath, then anointing him with 
tar, and finally returning him to the bath, where he remains for from 
four to six hours. For localized eruptions, green soap in combination 
with tar and alcohol serves an exceedingly useful purpose, either in 
the proportion of equal parts of the three ingredients, or by combining 


i other proportions, as, 

for example: 


R.—Saponis viridis, 

3iv; 

130 

01. rusci, \ 

Glycerin., j 

aa 3j; 

30 

01. rosmarin., 

3jss; 

7 

Spts. vin. rectif., 

Oss; 

500| 


Sig.—For external use. 


Other combinations of service are Bulkley’s u liquor picis alkali- 
nus,” the formula for which is given in the chapter on Eczema; or 
Wilkinson’s salve, as modified by Hebra, the latter combining the 
remedial effects of sulphur, tar, and soap, as follows: 


R.—Sulphur, sublimat , \ 

01. rusci [crud. vel rectif.], J 
Saponis viridis, \ 

Adipis, j 

Cret. pneparat., 

Sig.—Wilkinson’s salve, modified. 


aa ^ ss; 


aa 3j; 

9ijss; 


ie 

30 

3,5 M. 



INF LAMM A TIONS. 


269 


Where the sensitiveness of the skin to the action of tar has not 
been tested, or when the skin is particularly tender, a small quantity 
of the Wilkinson salve may be added to any simple ointment, or Spen¬ 
cer’ s ointment of tar (see the chapter on General Therapeutics) may be 
substituted; afterward 1 drachm (4.) of the oil of tar, or of oleum 
rusci, to the ounce (32.) of oil of almonds or of alcohol, may be 
employed. 

When toleration is established the tar may be rubbed over the 
patches in a pure state with a stiff brush, a procedure preferred in 
some parts of Germany, after which the patient either remains for some 
hours in bed, or is powdered with soapstone and bandaged with flannel, 
so that when the clothing is replaced it may not adhere to the tar. 
Naphtbalin, ichthyol, and carbolic acid operate in psoriasis in the same 
way as the tars, but are decidedly inferior to tar. 

Absorption of any tarry compound applied externally may result 
in general toxic symptoms, including fever, vomiting, diarrhea, stran¬ 
gury, and elimination of the toxic agent in secretions which are black¬ 
ened by its presence. These symptoms are usually relieved in from 
twenty-four to forty-eight hours after the discontinuance of the drug. 

Kaposi 1 2 was the first to employ beta-naphtol (the formula being 
C 10 H 8 O) in psoriasis, as also in eczema. It may be applied in alco¬ 
holic solution. Under the employment of a 15 per cent, ointment, 
the author reported speedy disappearance of psoriatic patches. It did 
not stain the skin, hair, or nails. 

Balmanno Squire, 3 however, reports that naphtol was in certain ex¬ 
periments conducted by himself, without appreciable effect when used 
in the strength of from 10 to 12 per cent., and that, when he increased 
the quantity of the agent until the ointment was applied in the strength 
of 25 and even 50 per cent., there was the production of merely irrita¬ 
tive effects. 

By many practitioners chrysarobin (or chrysophanic acid) is placed 
superior to all the tars in the local management of psoriasis. It is a 
crystalline powder of the color of old gold, insoluble in water, but is 
readily dissolved in hot alcohol, acetic acid, benzol, vaselin, and hot fat. 
It is derived from the “Goa powder” of the East Indies, or the 
“ araroba powder” of Brazil, araroba em po, s whose employment in 
psoriasis was first recommended in 1878 by Squire, of London. 

This drug is best applied in the form of an ointment, varying in 
strength from \ scruple (0.666) to 1 scruple (1.333) to the ounce 
(32 ) of vaselin or of cerate. It is occasionally used in lesser and 
greater strength, but, with pure specimens, it is liable in larger pro¬ 
portions to produce disagreeable effects. These effects are declared in 
a hot, itching, swollen, irritable, and erythematous skin, stretching 
from the surface of application, with tolerable uniformity, in every 
direction. Even in the strength named above it is necessary to begin 
its use with caution, testing it by application first to a limited area of 
integument. These excessive affects usually subside in a few days. 

1 Wien. med. Wochenschr., May 28, June 4 and 11,1881. 

2 British Medical Journal, January 14, 1882. 

3 This drug was obtained from Messrs. Silva, Limaos & Co., of Bahia, Brazil. 


270 


DISEASES OF THE SKIN. 


When the drug produces its most brilliant effects the psoriatic patch, 
previously denuded of its scales, assumes a whitish and normal aspect, 
contrasting thus somewhat remarkably with the chocolate to brownish- 
black discoloration of the stained skin at the periphery. This color¬ 
ation, when produced either by the ointment directly or by a frequent 
transfer of its ingredients to other parts by the medium of the cloth¬ 
ing and the hands, involves also the nails, the hairs, and the under¬ 
linen of the psoriatic patient. Its employment upon the face and 
the scalp is thus largely interdicted. The staining of the skin and 
its appendages disappears entirely in time, but always slowly. 

An improved plan of using chrysarobin externally has been sug¬ 
gested by Fox, 1 of New York, as follows: 

A soft paste, made by rubbing chrysarobin with a sufficient quantity 
of water, is smeared upon the psoriatic patches, the scales of which 
have previously been removed by one or more hot baths, with soap 
friction. As soon as the paste has dried, which it does in one or 
two minutes, a layer of collodion should be allowed to flow over each 
patch, and to harden into a protective coating. This coating will 
remain in place for several days or longer, according to the location 
of the patches; when it falls or is washed off, the application of the 
powder and the collodion should be repeated. By this procedure the 
chrysarobin in full strength is kept in contact with the affected skin, 
and is prevented from exciting undue inflammation of surrounding 
parts, or from staining the clothing. A mixture of the powder and 
the collodion may be used, but it is less efficacious. A film of collodion 
doubtless interferes with the action of the acid upon the skin. A some¬ 
what similar plan consists in the use of gutta-percha tissue to retain a 
strong chrysarobin ointment in contact with psoriatic patches. The 
edges of this tissue will adhere tightly to the skin if a small cameks- 
hair brush, dipped in chloroform, be passed rapidly beneath them. 

More recently, following Auspitz* s plan, Fox has added ten parts of 
chrysarobin and ten of salicylic acid to fifteen of sulphuric ether and 
one hundred of flexile collodion. This mixture rapidly dries over the 
psoriatic patch, where its specific effects are produced. 

Pyrogallic acid, first suggested as a remedy for psoriasis by Jarisch, 
is inferior to chrysarobin. The fact that several deaths have been 
reported as consequent upon the use of this acid deters many from 
making trial of it in a painless and merely disfiguring disease. It is 
used in a 10 per cent, vaselin ointment, is effective though less rapid 
in effect than chrysarobin, is cheaper, is odorless and painless, and it 
discolors to a less extent the sound skin. Both remedies are capable 
of being absorbed from the skin-surface, and of producing constitu¬ 
tional symptoms, pyrexia, strangury, and blackish evacuations. But 
in the case of pyrogallic acid only have fatal results been known to 
follow. 

Crocker, of London, similarly uses thymol in ointment, J scruple 
to J drachm (0.666-2.) to the ounce (32.); and Williamson advises 
turpentine, 2 drachms (8.) to the ounce (32.) of olive oil, with the 


1 The Medical News, March 18, 1882, p. 289, 


INF LA MM A TIONS. 


271 


odor corrected by the oil of lemon. Charteris treated thus a single 
limb of a psoriatic patient, that was subsequently wrapped in wool, 
with the result of relieving the psoriasis of the other limb, possibly in 
consequence of the absorption of the remedy. The danger of strangury 
in cases of absorption must not be overlooked. 

The nitrate, as well as the iodids and oxids, of mercury is applied 
by many practitioners in the form of ointment to patches of psoriasis, 
usually few in number and limited in extent. The action of these 
agents, however, is inferor to those already named, and the range of 
their availability being quite limited, they should be esteemed lightly 
in the topical treatment of the disease. 

The local treatment of psoriasis of the scalp and the face with many 
of the articles named above is often forbidden by reason of their dis¬ 
agreeable odor, or their too energetic action, or the staining which they 
produce. There is no better substitute for them all in these regions 
than the ammonio-chlorid of mercury in ointment, from 10 to 30 
grains (0.66-2.) to the ounce (32.). In the same way, the tincture of 
benzoin may be employed, j- drachm (2.) to the ounce (32.) of salve. 

Salicylic acid is capable alone of securing relief in many cases. 
There are few better methods of its application than by making use 
of the Lassar paste, two parts each of zinc oxid and finely powdered 
starch rubbed together with four parts of vaselin. To this paste may 
be added the acid in desired proportion. With from 5 to 10 grains 
(0.333-0.666) a minimum of effect is producible; in the strength of 
from 20 grains to twice that amount the stratum corneum is usually 
reduced, over the part on which the paste is applied, to a whitish pulp 
which may be scraped away with a curette without difficulty. Other 
articles, more recently vaunted in the external treatment of psoriasis, 
are: thilanin, which seems really to possess some value; hydracetin; 
rufigallic acid, 10 per cent, in unguent form : cupric oleate; anthra- 
robin; and gallacetophenol 5 to 10 per cent, in salve or in traumaticin. 
When practical, the skin affected with psoriasis should always be 
exposed in a sufficiently warmed apartment to the direct action of sun¬ 
light. By this measure alone the skin is often relieved of its eruption. 

Prognosis. The permanent relief of psoriasis is not insured by any 
treatment of a grave case, though hundreds of cases are permanently 
relieved by even the simplest treatment. The disease often recurs, and 
may do so repeatedly for the greater part of a lifetime. Permanent 
relief, therefore, should never be either predicted or promised in any 
case. Once relieved, it should be the aim of the practitioner to guard 
against all possible recurrences. After relief of any obstinate or recur¬ 
rent attack, as also in all inveterate cases, the prognosis is greatly 
improved by removal to a climate suitable for the psoriatic patient. 


272 


DISEASES OF THE SKIN. 


PITYRIASIS MACULATA ET CIRCINATA. 

(Pityriasis Rosea, Herpes Tonsurans Maculosus, Pityriasis 
Circinata. Fr ., Pityriasis ros£e de Gibert, Pityriasis 

CIRCINE ET MARGINS.) 

Pityriasis maculata et circinata is a mild febrile disorder of specific character and 
determinate course, in which appears a cutaneous exanthem in the form of mul¬ 
tiple, circumscribed, superficial, roundish or oval-shaped, yellowish and reddish 
patches, covered with fine scales, and seated for the most part on the trunk. 

This disorder has been recognized and carefully described by Gibert, 
Bazin, Horand, and Duhring. It is non-contagious and benign in its 
course, lasting from a few weeks to three months. 

Symptoms . The subjects are children, or more commonly young 
adults, but it is seen in middle life in both sexes. The outbreak 
of the disease may be preceded for a variable time by languor, lassitude, 
inappetence, or a feeling of chilliness. Occasionally the first noticeable 
symptom is the occurrence of mild fever, the body-temperature rarely 
rising above 102° F. 

The eruption often escapes recognition for a time after its appearance 
on account of its sparseness or the trifling degree of pruritus it arouses. 
When fully developed it is characterized by the conspicuous appear¬ 
ance over large surfaces of the trunk, especially the integument cover¬ 
ing the clavicles, the ribs, and the scapulae, of numerous pin-head- to 
small-coin-sized, circumscribed, roundish, or oval-shaped, slightly 
elevated, macular or maculo-papular lesions. These lesions may be 
discrete, closely set together, or confluent, and instead of being elevated 
may be either ou a level with the general surface, or even slightly 
depressed, with an annular border. They are dry, covered with fur- 
furaceous scales, and vary in color from a yellow or tawny shade to a 
deep red. The iufiltration is slight, and the patch is superficially 
situated. 

The oval contour is that more often recognized as characteristic of 
a well-developed lesion, the long axis of the disk usually corresponding 
with the lines of cleavage, and the terminal extremities of the oval 
sightly frayed by the irregularity with which the fine branny scales are 
there disposed. A tawny, salmon-shaded hue is highly characteristic 
of the disease, the patch slightly enlarging by peripheral extension, and 
leaving a relatively clear centre. The scales have oftej a silvery gray¬ 
ish color. The eruption may be tolerably well generalized, but the face 
and other exposed parts of the body usually escape, though the scalp 
may be involved. In the latter event the hairs are unaffected. 

The variations exhibited by the exanthem in this affection are dis¬ 
tinct, but are scarcely ever sufficient to mask the characteristic appear¬ 
ance of the oval or circular plaques over the neck, the arms, the 
abdomen, or the extremities, sometimes first appearing over the latter 
and extending thence to the trunk. At times a retiform expression is 
given to the picture by coalescence of the patches. There may be 
moderate itching with nocturnal exacerbation, but the usual type of 


INF LAMM A TIONS. 


273 


the disease is mild. Complete involution is usually reached in the 
course of a week or at most of a fortnight. 

Etiology and Pathology. The causes of this disease are obscure. 
According to Bazin, it occurs chiefly in lymphatic and scrofulous 
patients. 

The most of cases occur in patients having light hair and delicate 
skins, who have been enfeebled by great physical fatigue or by over¬ 
taxation in school. Profuse perspiration has been assigned as a cause 
by Horand. 

Diagnosis. The disease is to be differentiated from ringworm of 
the body by the absence of vesicles, the tendency to symmetrical dis¬ 
tribution of the lesions, their multiplicity, the characteristic yellowish 
centre of the oval rather than circular patch, aud the constitutional 
symptoms. Psoriasis differs greatly in the color, quantity, and char¬ 
acter of the scales present, and in the contour of the patch. In the 
scaling svphilodermata, the region of the body involved, the presence 
of plantar and palmar lesions, the constitutional symptoms and history, 
and the color of the patch, which is usually of a deeper and dirtier 
red than in the disease under consideration, will point to the diagnosis. 
In the macular syphiloderm (“ syphilitic roseola”) the closer prox¬ 
imity of the lesions will point at once to the difference, since the 
patches of pityriasis maculata et circinata are, as a rule, far more 
widely separated. The greasiness of seborrheic scales and the pallid 
hue of the integument beneath, when the former are removed, differ 
from the congested skin beneath the dry scale in this form of pityriasis. 

The treatment is expectant. Quiniu, sodic salicylate, and, later, 
ferrugiuous tonics are indicated in most cases. Locally, tepid bath¬ 
ing in the alkaline or the bran bath is usually found grateful. This 
bath is to be followed by the application of a dusting-powder. 


DERMATITIS EXFOLIATIVA. 

Exfoliative dermatitis is a more or less generalized cutaneous disorder in which, 
either in circumscribed patches or over the entire surface of the body, the skin is 
reddened and covered with scales which are freely exfoliated from the surface ; 
the disease may be accompanied by febrile and other general signs of systemic 
disturbance. 

Some confusion, both as to the names of diseases and as to the diseases 
themselves, has existed in connection with the subject of all general¬ 
ized exfoliative cutaneous disorders. More investigation is needed 
before definite limits can be established for several of the dermatoses 
of this class. By some, the term “ dermatitis exfoliativa” is held to 
be synonymous with pityriasis rubra, a disease here separately con¬ 
sidered. In these pages pityriasis rubra is distinguished as a distinct 
disease, and dermatitis exfoliativa is made to include the exfoliative 
and exudative disorders of the skin not properly considered in any 
other connection. 

Classing these forms of exfoliative dermatitis together as for the 

18 


274 


DISEASES OF THE SKIN. 


most part of acute type, and distinguishing the chronic forms from 
the pityriasis rubra of Hebra, it may be said of them all that they 
present features of wide diversity. At one time exfoliative der¬ 
matitis begins and ends in a single patient as a well-defined, distinct, 
and specific disease of mild symptoms, definite career, and benign 
type; in another case it occurs as a sudden or a gradual change in a 
pre-existing disorder, such as an eczema or a psoriasis (Gamberini); 
again, beginning in one or another of the simpler forms described 
above, it may become chronic, and, in its symptoms and appearance 
be indistinguishable from pityriasis rubra. 

Symptoms. Exoliative dermatitis may be fushered in with mild 
febrile symptoms, which may have or have not been preceded by 
malaise, languor, or a variable period in which the general health 
has been impaired. Often, however, all prodromata are absent. 

The eruptive symptoms are a more or less shining and vivid redness 
of the skin in one or several plaques which become in the course of a 
week the seat of numerous fine bran-like scales. Any region of the 
body may be affected, though the articular folds of the skin, the gen¬ 
ital region, the head, and the trunk, are often the seat of the disease, 
which may involve consecutively one part after another until in a week 
or a fortnight the whole body-surface is invaded. The affection may be 
limited to one region, or several distinct regions may simultaneously be 
involved, as the head and the lower limbs, or the thorax and the exter¬ 
nal genitals. The hands and the feet are usually the last to be 
invaded. The eruption may appear in reddish patches of well-defined 
or of very indeterminate outline. The skin affected may be slightly 
or apparently not at all infiltrated and raised. The itching may be 
slight or be severe. The redness displayed in the shin which is the 
seat of the scaling may be of the brightest crimson, “ erysipelatous/ 7 
violaceous, or purplish shade, or with a faint suggestion of yellowness. 
The scales, which are usually formed in the greatest abundance, are 
commonly seen loosely covering the reddish integument upon which 
they rest, though they are also shed in profusion when the affected 
surface is lightly swept with the hand. They are always whitish, 
minute, and bran-like, never in the so-called “ pastry-crust 77 condition 
of the scales in pemphigus foliaceus. 

In well-marked cases the features may be slightly disfigured by 
tumefaction of the lips, swelling of the ears, and puffiuess of the eye¬ 
lids. In all cases the skin is dry and is never moistened by a path¬ 
ological discharge. The scales shed in abundance are always white, 
imbricated, and silvery in hue; they are usually larger and coarser 
upon the lower limbs than over the neck, face, or chest. 

In the course of the disorder the hairs may fall, and, in some cases, 
the resulting alopecia is general. When the nails also are lost there 
is rarely any special pre-existing onychia to be noted. The mucous 
surfaces of the eyes, nose, mouth, and throat may participate in the 
general disorder and become the seat of inflammatory and, in rare 
cases, even of pseudo-membranous and exulcerative processes. 

The itching may entirely be absent; when present and in severity 
it is relieved even before the complete restoration of the integrity of 


I NFL A MM A TIONS. 


275 


the skin. The itching is apt to recur with each relapse, at which time 
also the fever is usually relighted. 

In most cases the disease is terminated in the course of two or three 
months, after which convalescence from the emaciation and possible 
complications (furunculosis, abscesses, etc.) may require an equal 
length of time. Pigmentation is always left for some time after the 
restoration of the health of the skin. 

Pathology. Brocq 1 has made a specially careful study of this dis¬ 
order, and his results are more or less confirmed by Vidal and Baxter. 
These observers recognized an infiltration of the papillary layer of the 
corium with embryonic cells, dilatation of the papillary and sub- 
papillary vessels, disappearance of the stratum granulosum and stratum 
lucidum of the epidermis, and appearance of nuclei in the cells of the 
stratum corneum. According to Quinquaud, 2 a diffuse myelitis and 
parenchymatous neuritis of cutaneous nerves may be responsible for all 
these changes. 

Etiology. Brocq relates that the disease affects patients who have 
not previously suffered from any cutaneous malady. The disorder is 
rare, and is said to occur more often in adult male subjects. 

Diagnosis. Exfoliative dermatitis is to be distinguished from pity¬ 
riasis rubra by the variety of its symptoms and course; from pemphigus 
folicaceus by the absence of bullae and grave systemic trouble; and 
from scarlet fever by the absence of sore throat and much more tardy 
evolution. Though, in general, a disease having a cyclical career and 
special characteristics, it may at times be lighted into activity by a 
diffuse psoriasis of acute type, or a squamous eczema becoming gen¬ 
eralized. In such cases the diagnosis is qualified by the pre-existing 
disorder. 

Treatment. The disease is unquestionably most readily relieved by 
any medicament which induces profuse sweating; hence, both jaborandi 
and pilocarpin have been employed in it with even brilliant success. 
Quinin, the sodic salicylate, and the mineral acids are often indicated. 
The strength of the sufferer is always to be supported by appropriate 
measures. Hebra’s diachylon ointment, one part to four of vaselin, with 
from 5 to 10 grains (0.33-0.66) of salicylic acid to the ounce (32.) of 
the whole, is usually most grateful to the skin. One of the combinations 
of lime-water, olive oil, and the oxid of zinc, described in the treat¬ 
ment of Eczema, may, however, be well employed as a substitute for 
the ointment. 

Prognosis. The disorder may prove fatal in exceptional cases; gen¬ 
erally, however, recovery may be expected. Often convalescence is 
tedious, protracted, and complicated by the occurrence of furuncles 
and cutaneous abscesses. 

Dermatitis Exfoliativa Infantum. Under this title Von Bit- 
tershain 3 and others have described an exfoliating non-contagious dis¬ 
ease of the skin in infants from six days to five weeks old, the disorder 
running from seven to ten days. It is developed as an erythema with 

1 Arch. gen. de Med., 1884. 2 Bulletin de la Societe Anatom., 1879. 

3 Centralzeitg. f. Kinderheilk., 1878, Bd. ii. 


276 


DISEASES OF THE SKIN. 


dryness of the skin, from which branny scales are exfoliated, leaving 
a peculiarly dry, reddish, and fissured integument beneath. The angles 
of the mouth and the mucous outlets generally are specially involved. 
Often buccal lesions are present. The face and the limbs are the seat 
of the chief features of the disease. It lasts for about one week and 
is unaccompanied by fever. The malady occurs more often in boys 
than in girls. In severe cases crusts form where the rhagades exist, 
and there is considerable pain and constitutional disturbance. Occa¬ 
sionally the skin is attacked by furunculosis after the disease has existed 
for a week. Relapses are common and recoveries occur in most cases. 

The treatment is by soothing applications to the cutaneous surface. 


PITYRIASIS RUBRA. 

• (Gr. navpa, bran.) 

(Dermatitis Exfoliativa. Ger., Rothkleie; Fr., Pityriasis 

RUBRA AIGU.) 

Pityriasis rubra is a rare, chronic, and usually grave inflammatory cutaneous disease, 
involving, as a rule, the entire surface of the body, in which the skin is deeply 
reddened and exfoliates lamellae of scales in large quantities. 

Symptoms. This disease is characterized throughout its course by a 
superficial hyperemia and inflammation of the skin, declared in patches 
or by a diffuse redness of a vivid or lurid tint, and by an abundance of 
small or large, lamellated, bran-like scales, which are continuously 
exfoliated from the epidermis throughout the course of the malady. 
Patients rarely present themselves for observation until a considerable 
portion of the body-surface is involved; but Kaposi states that in two 
patients observed by him the disease was first noticed in the neighbor¬ 
hood of the articulations. There are never at any time other lesions 
of the skin, betrayed in vesiculation, pustulation, moisture, or crust¬ 
ing. The palmar and plantar surfaces are usually less distinctly red¬ 
dened than the face and the extremities, having at times even a pallid 
hue, but they are always covered with a distinctly scaling epidermis. 

Under pressure with the finger the redness subsides or assumes a 
yellowish shade, while, as a rule, when the integument is gathered up 
between the finger and thumb, no thickening and infiltration can be 
recognized. Exceptions, however, have been noticed by several ob¬ 
servers. 1 The temperature of the skin is slightly increased. The exfolia¬ 
tion, as the disease progresses, is one of its most striking characteristics, 
the scales accumulating in large quantities about the coverings of the 
body of the unfortunate patient, who is engaged, as a French writer 
has it, in the labor of stripping himself involuntarily of his epidermis. - 

The d isease persists for mouths or for years, being always more 
severe in expression as it advances, the papery scales being shed more 
abundantly and in larger flakes, leaving beneath them a smooth, 

1 The author has reported one such case. Cf. Pityriasis Rubra: Chicago Medical Journal and 
Exam., Feb. 1881. 


INF LA MM A TIONS. 


277 


shining, occasionally purplish or even cyanotic skin. In the pa¬ 
tients observed by Jamieson, 1 of Edinburgh, the skin was so dark- 
hued as to suggest the color of a mulatto. Gradually the patient 
becomes conscious of an increasing sense of chilliness, as if deprived 
of sufficient body-covering. The itching may be absent, be moderate, 
or be severe. There may be instead sensations of stiffness, burn¬ 
ing, and tingling. Later, the integument seems to retract, as if it 
were insufficient to encompass the body, and becomes subject to fissure 
from extension and contact, while the lower extremities may even be 
cedematous. This retraction may be so marked that ectropion of the 
eyelid may ensue, and wide opening of the mouth may become difficult. 
The hairs and the nails lose their lustre and become friable, often 
falling, though at times they escape altogether. 

The influence of this gigantic, epidermal catarrh, involving, as it 
does finally, every portion of the body-surface, does not fail toward 
the end to be perceived by the vital forces. Alternating chills and 
febrile processes, pneumonias of a low grade, colliquative diarrhea, 
tuberculosis, subcutaneous abscesses, bedsores, and even gangrene of 
the skin may close the scene. 

Hebra and Kaposi together had under observation u about fifteen ” 
patients affected with pityriasis rubra, who, with a single exception, 
died from its effects. It will thus be seen that the disease is exceed¬ 
ingly rare. A few interesting cases have been reported by British 
authors. Among Americans, Duhring, George H. Fox, of New York, 
and the author, have published reports of cases. The disease is one 
of early or of middle life, and is pre-eminently of the male sex. 

The progress of the disease is both rapid and slow, lasting for years 
and at times ending with relative rapidity. In the course of a few 
days after its onset the entire body may be covered with the exanthem; 
yet when the disease is of long duration it may be at times partial and 
other times general in distribution. There are no red points visi¬ 
ble as in other forms of scarlatinoid-shaded eruption, and the color 
when the palms and soles are involved only appears after the thick 
epidermis of those regions has once been shed. Sweat may or may not 
be secreted in the course of the disease. The tongue is bright red in 
color in the early stages; later it is covered with a brownish crust. 
It is said at times to undergo a species of exfoliation. There may be 
a secretion which at certain times stains the linen. Iihagades may form, 
especially in the palmar and plantar regions. It is to be remembered 
that while in the instances of this disorder first described in Vienna 
there was never exhibited infiltration of the skin, this change has been 
observed in other typical instances. The nails may be separated, tilted 
up from the nail-folds, softened, thinned, fissured, “ worm-eaten/’ or 
otherwise altered. The chief systemic symptoms recorded are: languor, 
chilliness, and even severe rigors alternating with febrile temperatures 
of recurrent type, albumiuuria, diarrhea, pulmonary oedema, icterus, 
interstitial pneumonia, bronchitis, and rheumatism. 

The cases reported frequently by English authors are mostly 

1 Edinburgh Medical Journal, April, 1880, p. 879. 


278 


DISEASES OF THE SKIN. 


instances of exfoliative dermatitis following lichen ruber, eczema, 
psoriasis, and other simple dermatoses. In this class in particular 
belong the patients reported as suffering from repeated attacks of the 
disease; and those also in whom the disease is limited to but few 
regions of the body, such as the palms and soles. 

Etiology. The causes of the disease are absolutely unknown. It 
will be seen that the few cases which have been recognized furnish 
but an insignificant field for the study of the malady. It is more 
common in men than in women, and in adults rather than in chil¬ 
dren. It is interesting, however, to note, in this connection, that 
the constitutional symptoms of each case seem to have been induced 
by the disease of the skin, and not the latter by any internal derange¬ 
ment of which the symptoms are made manifest. For not only do 
visceral troubles occur chiefly at a late period of the malady, when 
common observation suffices to show that the cutaneous mischief alone 
is sufficiently extensive to induce them, but it is also clear, from the 
wide range of these disorders (bowels, lungs, etc.), that no special 
visceral malady has excited the cutaneous disease. 

Pathology. The researches of Hans Hebra 1 demonstrated in two 
cases that in the earlier period of the disease there is an infiltration 
of the integument moderate in degree, succeeded at a later period by 
cutaneous atrophy, in which the rete and papillae of the corium disap¬ 
pear. The connective-tissue elements undergo sclerosis; and the 
glands and the follicles of the skin are destroyed. Pigmentation is 
abundant. 

Both Hebra and Fleischman discovered coincident pulmonary, intes¬ 
tinal, or cerebral tuberculoses; and Kaposi, in one post-mortem exam¬ 
ination, established an atheromatous condition of the arteries. 

Baxter, * in the case of a patient examined by him, discovered no 
trace of the stratum granulosum, nor was the stratum mucosum com¬ 
pletely separated from the stratum corneum. There was a gradual 
transition from the polygonal prickle-cells below, which readily stained, 
to the horny cells above, which remained colorless. Flattened and 
faintly stained nuclei lay parallel with the surface, and they could be 
recognized even in the enormously hypertrophied stratum corneum. 
The papilke were enlarged; the interpapillary projections of the rete had 
pushed deeply into the corium. The prickle-cells of the hair-sheaths 
were multiplied. The remarkable consistency of the thickened corium 
at the outset of the disease was regarded by Baxter as chiefly due to 
a fluid exudate, which was observed before death. 

Myelitis was recognized in one case by Jamieson, who has been fol¬ 
lowed by others in the recognition of central and peripheral neurotic 
alterations. 

Diagnosis. It is clearly necessary to add to the facts given above, 
that many cases loosely reported as instances of pityriasis rubra are not 
really such. The misinterpreted symptoms are often those of an 
unusually extensive psoriasis or a chronic squamous eczema, which 
commonly terminates favorably in the course of proper treatment. 


1 Vierteljahr. f. Derm. u. Syph., 187o, Heft 4, p. 508. 


2 British Medical Journal, 1879. 


INFLAMMATIONS. 


279 


Experts are often summoned to see such eruptions, the import of which 
has been misunderstood. 

In lichen ruber the essential lesion is a papule, which even in the 
later extensive scaling of that disease usually may be recognized in 
some part or another of the infiltrated skin. 

Psoriasis rarely extends over the entire surface of the body, but at 
times it is thus generalized. In these very exceptional forms a long 
history of typical psoriatic patches may usually be obtained, while the 
bleeding surface beneath the scales and the character of the latter will 
point to the true nature of the disease. Psoriasis occurs in healthy, 
pityriasis rubra in cachectic, constitutions. Extensive erythematous 
or squamous eczema, apart from all other symptoms, can be recognized 
at once by the excessive distress occasioned by the eruption. The patient 
lies in bed nursing his or her tender limbs, back, or belly. In pity¬ 
riasis rubra the patient rises, dresses himself, and moves about with 
an expression, not of pain, but of listless apathy. His scales are not 
scanty and adherent, but are abundant and exfoliate freely. There is, 
from first to last, in his case no history of moisture. In every gener¬ 
alized eczema there will always, at one point or another, be a surface 
which weeps. In its early periods pityriasis rubra can be distinguished 
from pemphigus foliaceus by the absence of bullae and of the intoler- 
ble stench which is then often emitted by the sufferer. When, how¬ 
ever, there is present merely a generalized exfoliative dermatitis, the 
two disorders may well-nigh be indistinguishable. 

Treatment. Arsenic administered internally seems powerless in 
pityriasis rubra. Cases are on record of fatal results after the exhibi¬ 
tion of this drug in prodigious quantities for long periods of time. 
Tar externally promises no better result. Kaposi reports a single patient 
relieved by the use internally of carbolic acid. Thyroid extract may 
be tried in chronic cases. 

A roborant treatment, including the employment of cod-liver oil, 
iron, or quinin, is certainly indicated, with externally the simplest 
bland unguents, of which vaselin seems best tolerated. It should be 
employed, not merely to soothe, but also to protect the skin. The 
clothing should be ample and unirritating, and the diet carefully 
selected with a view to supporting the strength. 

The prognosis is necessarily grave. 


PITYRIASIS RUBRA PILARIS. 

(Lichen—psoriasis. F/\, Pityriasis rubra Pilaire.) 

Pityriasis rubra pilaris, or follicularis, is a desquamative affection of the skin, in 
which, while the general health may be unaffected, the cutaneous surface is altered 
in degrees varying from that grade in which numerous fine, dry, or greasy scales 
are shed from its surface, to that in which the latter is converted into a horny, 
dense, or coriaceous mass 

This affection has chiefly been described in France by Devergie, 
Besnier, Richaud, and others. The museum of the Saint Louis 


280 


DISEASES OF THE SKIN. 


Hospital is amply provided with illustrations in wax of every phase of 
the malady. In other countries it has until recently either been de¬ 
scribed under a different name or has wholly been ignored. Cases of 
the disease in sufficient number have come under the observation of 
experts in America in the past few years. It is probable that the 
malady is identical with the lichen ruber acuminatus of Hebra. 

Symptoms. The disease commonly appears as a seborrhea sicca of 
the hairy scalp, with and without palmar and plantar scaling patches, 
though the face may be first to exhibit the signs of the affection. The 
eruption may be preceded by sensations of malaise, insomnia, hyper¬ 
esthetic symptoms, or by a feeling of stiffness in the skin. The 
first symptoms are usually the occurrence of very fine desquamation; 
soon after there appear over the surfaces of the fingers, hands, fore¬ 
arms, elbows, knees, waist, or belly, minute papules, firm, dry, and 
silver-white, reddish-brown, or rosy-yellow in color. Each of these 
papules has evidently been pierced by a hair, and about its apex where 
thus traversed by the pilary filament there is a delicate sebo-corneous 
sheath which penetrates the hair-follicle for a short distance. These 
papules may be as minute as a millet-seed or larger, but are never of 
the size of that of a split pea. They become more and more numerous, 
and appear at times to coalesce, and may form a patch covered with fine 
elevations—conical and discrete; or may be lost in the general scaling 
and exfoliating,erythematous and shining area. The apex of each conical 
elevation may display an unbroken hair or a mere stump of the same, 
or a black point, the surface presenting then the appearance of the 
shaven beard. The yellowish-red or deep reddish patches may be the 
seat of either pityriatic scaling, or may exhibit separation of the epi¬ 
dermis in large, adherent flakes, which over the elbows and the knees 
particularly present the appearance of psoriasis. Commonly at the 
borders of these patches there can be found without difficulty the 
initial papules of the affection, still isolated and surrounding charac¬ 
teristic stumps, filaments, or black points of hairs, enabling one thus 
to make the diagnosis with ease. At times the eruption is completely 
generalized; when the face is chiefly involved the slight crusts formed 
are decidedly of the type of those described under Dermatitis (Eczema) 
Seborrho’icum. In many cases the tension of the skin which results 
produces ectropion of the lower lid. Occurring over the hairy scalp, 
the accumulated scales and crusts may furnish a dense and resisting cap 
which is difficult to remove. The nails are usually grayish, yellowish, 
longitudinally striated, and roughened. There may also be a coinci¬ 
dent polytrichia. Important for purposes of diagnosis are the little 
horny, blackish, conical papillae occupying the sites of the hair-follicles 
on the dorsal surfaces of the first and second phalanges of the fingers. 
These usually remain distinct even when the hands are completely 
invaded. The course of the disease is chronic, irregular, and subject 
to relapses and unexpected aggravations. The general health may 
remain unimpaired; the itching is slight. 

Etiology. The essential cause of the disease is unknown. It occurs 
rather more often in the male sex, but has been observed at all ages 
in both sexes. 


INF LAMM A TIONS. 


281 


Pathology. According to Jacquet, the papule, which is the essential 
lesion of the disease, represents merely a keratinization to an unusual 
degree of the epithelial lining of the superior portion of the hair-pouch. 
All the other changes in the skin are subordinate to the epidermal 
affection. Besnier recognizes four different types of the disorder, three 
of which are probably represented by a somewhat different process in 
the corium and epidermis. These types are: the sebaceo-squamous, 
or pasty form; the reddish, or pityriatic; the xerodermic, iii which the 
condition resembles that known as “goose-flesh;” and lastly, a “mixed” 
form. It is in these clinical pictures that the process, if it be in fact 
unique, may best be recognized, for in them are represented the familiar 
changes seen in eczema, psoriasis, keratosis (or lichen) pilaris, xerosis, 
ichthyosis, and possibly a few other affections of the skin attended 
with keratinization of the epidermis. 

Diagnosis. The disease is to be differentiated from all others by 
the characteristic papule pierced by the shaft, or segment of shaft, of 
a hair. In extensive cases of long standing the identity of the pap¬ 
ules may be lost in the general scaling process over most of the body, 
but in nearly all cases they can be recognized on the backs of the 
fingers, as described above. Ichthyosis is congenital; pityriasis rubra 
is more frequently generalized, and is a grave disorder affecting the 
general health, while pityriasis rubra pilaris does not always interfere 
with the systemic condition. The disease is by many supposed to be 
identical with lichen ruber acuminatus. For the differences between 
the two maladies the chapter on the last-named disease may be con¬ 
sulted. Psoriasis is never characterized by papules with hair-filaments 
in the centre. 

Treatment. The remedies hitherto found most useful in the local 
management of this disorder are those valuable in the management of 
psoriasis and squamous eczema. Tar, pyrogallol, chrysarobin, salicylic 
acid, and the mercurials, with lotions of Van Swieten’s liquor, are 
advised, and, when an inflammatory effect is produced, the employment 
of soothing lotions and salves. Fatty crusts, when these are abundant, 
are to be removed by shampooings, as in seborrheic affections of the 
scalp. Internally, arsenic, cod-liver oil, and carbolic acid have not 
seemed advantageous. Brocq recommends for internal use the arse- 
niate of sodium in increasingly large doses, but no single remedy is 
known to be efficacious when administered internally. 

The prognosis is usually favorable. 


Epidemic Exfoliative Dermatitis. 

[Epidemic Skin Disease (Savill) ] 

During the summer and autumn of 1891 an epidemic disorder with 
cutaneous symptoms developed in several of the London asylums, 
infirmaries, and hospitals, affecting about five hundred patients. The 
disease was studied with special care by dermatologists and other med¬ 
ical men. The brief sketch given below is based upon an excellent 


282 


DISEASES OF THE SKIN. 


monograph with colored and photographic illustrations by Savill, 1 
on various communications made on the subject in the columns of the 
British Medical Journal and the London Lancet for 1892, and on the 
description given by Crocker in his treatise. 

The disease occurred in two distinct clinical types, one with catarrhal 
exudation from the skin, resembling the moist forms of eczema, the 
other, dry and non-discharging, resembling pityriasis rubra, and, 
according ’to Crocker, indistinguishable from that disease. 

The eruptive features were apparently not preceded by prodromata, 
but gastro-intestinal disturbance (vomiting, diarrhea), and in some 
cases sore throat, either preceded or accompanied the appearance of 
the dermatosis. Except in patients of advanced years, there was 
usually post-occipital and cervical adenopathy, not to be explained as 
sympathetic with a cephalic eruption. The regions most frequently 
involved were the upper limbs, the scalp, and the face; the lower 
limbs less frequently. 

The skin-lesions were pruritic and were irregularly grouped, acumi¬ 
nate papules, with a follicular site. 

The stages of the exanthem, as given by Savill, were: 

(а) A papulo-erythematous stage, lasting from three to eight days, in 
which the papules were felt shot-like beneath the skin,were discrete, and 
were seated on a reddened, thickened, even an indurated or oedematous 
integument. In some cases the onset was in the form of margin ate 
and circular nodose patches, resembling those seen in erythema nodo¬ 
sum ; in a few the resemblance was to ringworm, flattened papules 
enlarging to a circinate annular group with minute central vesicles 
readily ruptured. 

(б) An exudative stage. In this stage, lasting from three to eight 
weeks, papules, vesicles, or macules soon formed a confluent eruption, 
the skin being of crimson hue, thickened, and scaling in flakes, or in 
lamellated crusts in consequence of the exudation. In the moist type 
the papules developed to vesicles with exudation; in the dry type the 
exfoliation occurred in purer scales, pints of which in some cases could 
be collected from a patient’s skin in a day. In other cases this exfoli¬ 
ation was in the form of an impalpable powder; it was characteristic 
in some degree of all well-marked cases. 

(c) A stage of subsidence. In this stage the disease proceeded to 
involution, leaving the skin at first indurated, polished, and brownish 
in color. In many cases the new skin was raw and parchment-like, 
smooth, shining, and readily fissured, resembling in this respect ichthy¬ 
osis. In a few instances ectropion resulted, as a sequel of conjunc¬ 
tivitis. In severe cases the hair and all the nails were shed. There 
was a mortality of from 5 to 13 per cent., death resulting from exhaus¬ 
tion with the usual signs of subsultus, shallow respiration, and coma. 
Complications occurred in the direction of pneumonia, gangrene, and 
albuminuria. A few of the attendants upon the sick, children, and 
patients of somewhat older years were attacked; but for the most part 

1 An Epidemic of Skin Disease resembling Eczema and Pityriasis Rubra, by Thomas D. Savill, 
etc., London, 1892. 


INFLAMMA TIONS. 


283 


the patients, and especially those succumbing to the disease, were indi¬ 
viduals of advanced years of both sexes, inmates admitted for the 
management of other disorders to the institutions where the disease 
prevailed. 

The etiology of the disease was not satisfactorily determined. Cocci 
were isolated and cultivated by Savill and Russell, but the etiological 
importance of these micro-organisms is yet to be demonstrated. The 
influence exerted upon the disease by parasiticides was beneficial to a 
degree; but this treatment on the whole was unsatisfactory and chiefly 
amounted to amelioration of the condition of the skin. 

Parakeratosis Variegata. Under this title Unna 1 and his 
assistants described two cases of patients affected with a dermatosis 
supposed to be idiopathic, the disease occurring as a yellowish, reddish, 
or empurpled eruption lasting several years, and at first affecting the 
neck, the chest, and the lower limbs; later involving the entire surface 
of the body with the exception merely of the head, the palms, and 
the soles. The infiltrated patches, which at times contrasted with 
apparently suuken areas of the intervening sound skin, were the seat 
of a pityriatic desquamation, were distinctly circumscribed, and were 
somewhat variegated in color, suggesting the name adopted in describ¬ 
ing the affection. Beneath the scales the surface was smooth and 
brilliant. 


LICHEN RUBER. 

(Gr. heixyv, moss.) 

(Lichen Ruber Acuminates, Lichen Exudativus Ruber, 
Lichen Psoriasis. Ger ., Rothe Schwindflechte.) 

Lichen ruber is an exudative cutaneous disease, characterized by the appearance 
of firm, millet-seed- to split-pea-sized, reddish, conical, flat, angular, discrete, or 
confluent papules, the evolution of which may* be accompanied by a moderate de¬ 
gree of itching, the eruption having a marked tendency to generalization and 
in some cases to the induction of a fatal marasmus. 

Under the term lichen ruber Hebra was first to describe the disease 
which is now recognized under this title. It is a malady rare of occur¬ 
rence, yet is more often recognized and described on the continent of 
Europe than elsewhere. Its exact relations to lichen planus and to 
pityriasis rubra pilaris have been the subject of extended discussion, 
the results of which have not yet definitely settled all the questions at 
issue. In these pages the disease is described as it exists in Europe, 
and from the standpoint of the best authors of that country; while the 
chapter devoted to Lichen Planus is designed to portray this affection 
as it exists in America and as it has been investigated by American 
observers. 

Symptoms. The disease is first chracterized by the appearance, with¬ 
out prodromal symptoms, of isolated, pin-head-sized, conical, reddish, 


1 Monatschft. f. prakt. Derm., 1890, vol. xi. 


284 


DISEASES OF THE SKIN . 


and scale-capped papules of considerable firmness, bright red or livid 
in hue, and disseminated over the belly, the chest, the genitalia, the 
extremities, and other portions of the body. In another form of the 
disease these lesions are lighter in color, each with a smooth surface, a 
small central depression at the apex, and a waxy appearance. The 
u nutmeg-grater ” effect is usually produced when the finger is passed 
over them. The itching excited may be mild or be severe; it bears 
no relation to the extent of the exanthem. 

The papules rapidly multiply, forming patches which, by aggregation 
rather than by coalescence, cover entire regions of the body, and, lastly, 
its entire surface. Throughout the course of the disease the individual 
papules do not enlarge at the periphery, but they persist as such until 
they are lost in a diffuse, dull-red, infiltrated patch, covered with thin, 
papery, grayish, non-adherent scales, beneath which the orifices of the 
hair-follicles are seen to be dilated. 

Occas : onally at the border of a patch thus formed, isolated, shining, 
flattened, or umbilicated papules persist or form circles of densely 
packed lesions, surrounding groups in which involution of the lesions 
progresses, leaving pigmented and atrophic areas within. 

Whether in the form of lesions last described, or after irregularly 
disposed disseminated patches have been developed, the entire integu¬ 
ment becomes eventually the seat of extensive infiltration, reddening, 
and scaling. As a consequence fissures form, and the distress of the 
patient increases. Bullae are occasionally observed. 

The skin of the face cracks; the eyelids are everted or are thickened; 
the skin of the palms and soles is converted into a leathery tissue; the 
nails become friable and irregular; motion at the joints is excessively 
painful on account of the inelasticity of the skin covering the articu¬ 
lations; the hairs are thinned and fall; the extremities are maintained 
in a position midway between flexion and extension. The integument 
is now universally reddened, is covered with innumerable delicate or 
with coarse scales, and, especially upon the palmar and plantar sur¬ 
faces, is thickened by dense infiltration. Over the deeper fissures, 
extending to the corium, there form blackish and blood-containing 
crusts. Emaciation progresses pari passu with the invasion of the 
disease, and death may result from exhaustion, intercurrent diarrhea, 
or pneumonia. 

Lichen Buber Planus (as a variety of lichen ruber acuminatus) 
is regarded by most writers as identical with lichen planus. Minute 
yellowish to reddish papules, irregular, differing in shape but often 
polygonal, and varying in size from that of the minutest lesions to 
those as large as a pin-head, firm, and dry, rise from the affected sur¬ 
face of the skin, often at the site of a hair-follicle whence the pilary 
filament has disappeared. Desquamation does not occur, as a rule, 
while these lesions are isolated; when confluent, there may be consid¬ 
erable scaling. The itching may be mild or be of the intensest grade. 

The eruptive symptoms may persist in discrete form as at the outset, 
the exanthem spreading by multiplication of new lesions until the entire 
surface is involved. At certain points there may be confluence with 


INF LAMM A TIONS. 


285 


formation of a flatfish elevated plaque, light or dark reddish in hue, 
and irregular in outline, with considerable infiltration of the integu¬ 
ment. Grayish scales are then produced, often with whitish striae 
radiating from the patch. Annular bands and also other figures which 
may be geometrical in contour are thus formed. Occasionally there 
are vesicles and vesico-pustules. Deep pigmentation may succeed 
complete involution of the disorder. The wrists, the forearms, the 
belly, the lumbar region, the inferior extremities, and in men the 
genital regions, are most often involved. 

The variations of the affection are: an extreme grade of exfoliation 
of the epidermis in large plates, with a raw, reddish surface beneath, 
surrounded by a fringe of reddish or yellowish scales. On the palms 
and soles the lesions may closely resemble a syphiloderm of these parts, 
even to the leaving of minute pits or depressions where the epidermis 
has fallen. In other occasional cases, according to Brocq’s description, 
the papules exhibit blackish points in the centre corresponding with 
the orifices of coil-glands. It is also noted that the disorder may affect 
the mucous surfaces, as is described in the ensuing chapter. The dis¬ 
ease even may progress in a chronic course for months or for years 
without marked modification, or, on the contrary, the evolution may 
be very rapid, the eruptive elements being large, the skin greatly 
infiltrated, the sheets of eruption vast, and the general distress great. 
Bullae and vesico-pustular lesions are observed in rare cases. 

Mixed Forms are reported by several authors, in which forms all 
the symptoms of lichen ruber acuminatus and lichen ruber planus have 
been exhibited in one patient. In some patients the one form of dis¬ 
ease has been noted to precede; in yet other cases, another form. 
Instances are recorded in which all the lesions of typical lichen ruber 
acuminatus and planus have coincidently been observed in one patient 
at the same time. 

Unna, of Hamburg, has attempted to create yet another clinical 
variety of lichen ruber, under the title Lichen Buber Obtusus. In 
a first variety the lesions are semicircular, pea-sized, flattened, polished, 
waxy papules unprovided with scales, having a bluish-red or brownish- 
red depression in the centre. The itching is usually intense, the papules 
may coalesce, and the eruption may become generalized. Pigmentation 
has been observed after involution is completed. Occasionally cica¬ 
trices have formed. 

In a second variety, the corneous form, described by the same author, 
the papules are large and are seated for the most part on the extremi¬ 
ties. The itching is intense. As individual lesions increase in size 
the tinting becomes brownish, and over these elements form small, 
grayish, dry, adherent scales, which give a cornified aspect to the surface. 
Some of the papules persist without coalescence throughout the attack. 

These two forms are evidently merely clinical variations of the dis¬ 
order described fully by authors. 

Lichen Buber Moniliformis (Kaposi) is an odd-looking disorder 
(of the lichen ruber class), in which numerous node-like masses are 


286 


DISEASES OF THE SKIN. 


arranged in lines and chains resembling the necklace of jewellers, 
with flattish, punctiform papules between the nodes, and macules of a 
sepia-brown hue between the lesions. 

Etiology. The cause of the disease is unknown. The sexes seem to 
suffer in equal proportion, though it is claimed that more men than 
women are affected. The disease is transmitted neither by heredity 
nor by contagion. In those who display the symptoms of the affec¬ 
tion external irritation is capable of aggravating the eruption. The 
disease is chiefly encountered in middle life, from the tenth to the 
fortieth year, but it has been observed as early as the eighth month. 
It is probably a tropho-neurosis. Cases have been reported following 
traumatism and shock. Well-marked instances of the disorder have 
been recorded in persons otherwise healthy. La^sar discovered minute 
bacilli in the lymph-spaces, but they have not been shown to be the 
effective causes of the malady. 

Diagnosis. In psoriasis the discovery of a typical scaling patch, 
often with a clearing centre, should suffice for recognition of that dis¬ 
ease. The scaling in diffuse psoriasis is also much more abundant. 
In papular eczema the lesions do not persist as such. When these 
two affections are generalized it is claimed by French observers that 
there is always some one area, however small, of unaffected integu¬ 
ment. This unaffected area is not to be found in generalized lichen 
ruber; but, in such generalized cases, the distinction between that 
disease, pityriasis rubra, or dermatitis exfoliativa may be extremely 
difficult, if at all practicable. At an early period papules are not seen 
in either of the last-named two disorders. The papules of syphilis 
never scale so generally as those in lichen ruber; moreover, they increase 
in some cases to double their original size, and are always accompanied 
by some other symptom of that disease. In the scaling stage of pem¬ 
phigus foliaceus there are bullae present or there is a history of these 
lesions pre-existing. 

Lichen ruber is to be distinguished from pityriasis rubra pilaris by 
the non-limitation of the former to the orifices of follicles ; by the later 
period of its scaling; by its deeper involvement of the skin; by its 
greater diffusion over the extensor surfaces of the body; by its severe 
grade of pruritus; by its involvement of the general system; by its 
frequent grave issue; by the deep pigmentation remaining; and by its 
occasional involvement of the mucous surfaces. 

Pityriasis maculata et circinata is a much more superficial and a 
milder affection; its scales are fewer; its rarer papules are smaller; and 
they occur chiefly at the periphery of its oval patches. 

Pathology. Lichen ruber is a paratypical keratosis of the superficial 
portions of the stratum corneum. It is characterized by hypertrophy 
of the stratum corneum and incomplete corneous transformation of 
the individual elements of that layer, which are larger and more polyg- 
oual, a feature most noticeable about the sweat-ducts and the hair- 
follicles. The rete is iu places enlarged in consequence of cell-infiltra¬ 
tion, and in places is normal. The upper portion has an uneven 
appearance as the interpapillary portion pushes slightly downward, and 


INFLAMMA TIONS. 


287 


the increase in size of the other parts is more marked. The papillse 
are increased in size, and their blood-vessels are dilated and surrounded 
by emigrated corpuscles. The walls of the sweat-duct are formed of 
large cells with vesicular nuclei; corneous cells are heaped also about 
the orifices of the hair-follicles; the muscle-bundles are much hyper¬ 
trophied. 

Treatment. Arsenic, which is of greatest value, can be employed 
with large chances of success in lichen ruber. This drug is early to 
be given, and persistently pushed in the face of new crops of lesions 
until the desired result is obtained, and to be continued for several 
months after all signs of the disease have disappeared. Tonics, when 
indicated, should always be exhibited. The diet should be generous. 

External treatment is naturally employed chiefly for the relief of 
any pruritic sensation. Here dusting-powders and ointments prove 
serviceable. The local remedies.employed in corresponding stages of 
eczema may, in brief, be here used with advantage, such as the alka¬ 
line, starch, or bran bath, followed by inunction of the skin with 
salves containing thymol, salicylic acid, zinc oxid. bismuth, carbolic 
acid, or benzoin. 

Prognosis. The prognosis of the disease, when it refuses to yield 
to treatment and tends to become generalized, is necessarily grave. 
Treatment, after the occurrence of marasmus, will often prove ineffect¬ 
ual. The disease is said to be occasionally amenable to energetic treat¬ 
ment, before it has advanced to the stage of inducing systemic 
exhaustion. 


LICHEN PLANUS. 

(Gr. Xeixf/v, moss; Lat. planus, flat.) 

(Lichen Ruber Planus.) 

Lichen planus is an inflammatory dermatosis, in which are displayed multiple, lucent, 
flat-topped, polygonal papules, often exhibiting a color suggesting crimson, the 
plane apex of each being usually depressed and at times scaling, with characteristic 
grouping of the lesions. 

This disorder has been the source of a considerable discussion due to 
the confusion which has existed in different countries respecting the 
question of its identity with or distinction from lichen ruber planus, 
since the date of the first written description (in 1869) of the malady 
by the late Sir Erasmus Wilson. Lichen planus at one time was rarely 
reported in America, but it is now among the affections occupying a 
second rank after those of most frequent occurrence. 

Symptom*. The elementary lesion of every classically developed 
eruption is a flat-topped, polygonal papule which, when studied in 
different positions so that the light falls somewhat aslant upon the 
surface, has a striking effect upon the eye. Thus examined, the char¬ 
acteristic glistening or shining top of each papule becomes conspicuous 
and presents a symptom scarcely so well shown in any other eruption. 

The papules exhibit a peculiar crimson or purplish shade, and when 


288 


DISEASES OF THE SKIN. 


the eruption is plentiful this color is so characteristic that bv it alone, 
in a well-marked case, the eruption may be recognized by the eye 
before individual lesions can be identified. The papules vary in size 
from those which are exceedingly minute and scarcely surpass in dimen¬ 
sions the head of a small pin to the larger lesions ( e . g ., of so-called 
“ lichen planus obtusus”), where the papules may be as large as pease 
or beans, and may even assume an annular form or may exhibit about 
the flattened top a ring of minute vesicles or of still finer papules. 

The individual lesions are at first discrete, but they tend to form 
irregularly arranged groups, which may assume a circular shape, or 
that of a figure with sharp angles. In no other eruption than lichen 
planus do eruptive elements form in distinctly straight lines and in 
variants from the latter, such as, e. g. y a figure representing a digit 
flexed at a right-angle. In this way are occasionally formed exceed¬ 
ingly odd-looking groups—parallel lines, cockades with scaling crests, 
rosettes, etc. 

As the lesions grow older they almost invariably distinctly deepen 
in shade, from a light crimson to a dull purplish hue, and still later to 
even a darker color. In typical cases the lesions of lichen planus when 
actually subsiding or well-nigh gone from the surface of either the 
chest or of the belly are apt to leave a smoky and even blackish hue, 
which is the result of the pigmentation produced when the disease is 
in greatest activity. These sequels of the disease are naturally most 
conspicuous on the lower extremities. 

The eruption is usually symmetrical, though it may occur in patches 
on only one side of the body. The most frequent site of the disease 
is the anterior face of the forearm, but lesions may develop upon any 
portion of the body-surface, especially the abdomen (more frequently 
its lower third), the extremities (in the point of frequency, first the 
upper and then the lower extremity), the hands, the penis, the back, 
the ankles, the inner side of the knee, and the neck. A typical dis¬ 
play of symptoms is not often to be seen on the face. 

When the papules have coalesced and also, as happens in extreme 
cases, when they have flattened so as to be indistinguishable before the 
disease has yielded, a crimson-hued sheet or mask of the skin is seen, 
generally characterized not merely by the color of the lichen papules, 
but also by a silvery sheen, due to thin shining scales which do not 
completely cover, but which supplement, as it were, the empurpled 
patches, beside and over which they form. These scales are not freely 
shed from the surface, yet they are not very firmly attached. 

The greatest variation is experienced in the way of subjective sensa¬ 
tions. In some patients the eruption is tolerated with but few symptoms 
of annoyance. In other patients the greatest possible distress is occa¬ 
sioned, and no subjects of scabies or of eczema suffer more. The erup¬ 
tion of lichen planus, however, is less often scratched than that of - 
other cutaneous exanthemata accompanied by severe pruritus. 

The disease is usually chronic iu course. In America patients 
of the better class commonly reach the end of their sufferings in the 
course of six months or a year. This fact seems to furnish a reason¬ 
able basis for the belief that treatment has a favorable influence upon 


INFLA MM A TIONS. 


289 


the malady, seeing that it is not rare to discover untreated patients or 
those in whom the nature of the disease has been long ignored, who 
for two and even more years have suffered from lichen planus in cir¬ 
cumscribed forms limited to a palm-sized patch over one popliteal 
space or a wrist; while another for six years and more may have been 
affected over an entire lower extremity or a shoulder. The disease is 
said to recur, but in America recurrence is decidedly an exception to 
the rule. In the rarer acute forms noted by observers the disease 
may be lighted up to activity from a chronic patch; or it may begin 
with acute symptoms. 

Lichen planus is remarkable for the irregular exceptions it offers 
in individual cases to the lesions seen in others. Thus, Crocker 1 
describes papules with a convex instead of a concave top; and cases 
in which the lesions were soft and compressible instead of possessing 
the firmness of the usual lichen-planus nodule. The lesions are occa¬ 
sionally interspersed with telangiectases, bullae, etc. 

When the mucous surface is affected the disease develops in whitish 
macules, or striae, or flat papules, the latter aggregated on both sides of 
the tongue, the striae running along the line of the jaws where the 
molar teeth come in contact. The affection in this region has unques¬ 
tionably often been confounded with leukoplasia (so-called “ ichthyosis 
linguae ”), elsewhere described. In the mouth the papules of lichen 
plauus are in rare instances conical at the apex. 

The disease most often attacks young adults and the middle-aged of 
both sexes. In children, who suffer but rarely, the eruptive features 
show a striking tendency to early flattening, and they thus simulate 
the macules of much simpler disorders of the skin. Lichen planus of 
the face occurs much oftener in children than in adults. A few cases 
of the disease have been recorded in infants, and these commonly 
among the dispensary class. 

Upon the lower extremities, after the disease has existed for a long 
time, a single band-like plaque of the disease may lose almost all 
papular features, and come to resemble a deep purplish keloid-like 
elevation or flat tumor embedded in the skin. When involution is 
complete there is usually very deep pigmentation and at times slight 
atrophy. 

Whitish points and streaks are visible at times in the smaller and 
larger lesions, the horny scales projecting from other lesions like thorns. 
Fantastic groups occur on the body in the form of a cockade or in a 
whip-shaped curve; the bands of papules may also assume odd and 
singular figures. At times, especially when the case is one of persistent 
and wholly discrete papules, linear bands of these lesions, one or sev¬ 
eral centimetres in length, of geometrical straightness, may be com¬ 
mingled with curved lines and even goitre-shaped figures. 

When there are decided sheets of infiltration they are most conspic¬ 
uous over the flanks and belly, but they may also be seen elsewhere, 
as, for example, over the extremities. Iu these cases the very peculiar 
color of the patch with indefinite outlines is characteristic, and is often 

1 Diseases of the Skin, second edition, 1893, p. 300. 

19 


290 


DISEASES OF THE SKIN. 


in brilliant contrast with the scales. The scales are of an exquisite 
silvery whiteness, very different in hue from the pearl-white or yellow¬ 
ish-white large scales of psoriasis, and equally distinct from the branny 
and yellowish fine scales of pityriasis maculata et circinata. They 
are by no means freely shed from these extensive patches, but they 
adhere and rarely cover the entire patch, nor crop out beyond its 
indefinite border, but produce a species of silvery sheen over its central 
portions. These patches are usually symmetrical, as are commonly 
also the discrete papules of extensive development. When either 
of these forms proceeds to involution the scaling ceases, the infil¬ 
tration subsides, and the intensely deep pigmentation left is charac¬ 
teristic of the disease, being often of a smoky, and even of a blackish 
hue. 

The course of the disease in America is always toward recovery; 
and while it may endure for months, it is rare that it lasts for years. 

Variations in the small or the large papules are occasionally observed. 
Minute vesicular points may be visible over their flattened surfaces, 
or there may be seen equally minute keloid-like processes, or reddish 
points, upon or between them, where the vascularity of the tissues 
beneath is apparent. Only as an exception to the rule are the polyg¬ 
onal papules clustered about the orifices of hair-follicles, as in pity¬ 
riasis rubra pilaris and lichen ruber. At times whitish points and 
streaks are left after the resulting pigmentation subsides. 

Bullae have been recognized as coincident features in but a few cases. 
Over the palms and soles the whitish spots, produced by exfoliation of 
the epidermis, may be the most conspicuous symptoms of the disease 
in those regions. 

Lavergne divides all cases of lichen planus into three classes. The 
first is chronic lichen planus, the disease as it is known in its most 
common form; the second is acute lichen planus, in which the papules 
rapidly develop, ani form extensive patches, thickened, painful, livid- 
red, and abundantly desquamating; the third form is the lichen planus 
corneus, of Vidal, Fournier, and Besnier. This form corresponds with 
the coin- or palm-sized, bluish to blackish, scaling and rugous, tumor¬ 
like plaques, usually seen on the anterior face of the leg, briefly 
described above. 

Lichenification. In certain portions of the integument, usually 
definitely circumscribed and of limited area, a significant change often 
occurs, which has been designated by the French “lichenification.” In 
such patches (marginate eczema, nevrodermite , etc.), found particularly 
about the flexures of the joints, the fork of the thighs, the back of the 
neck, and elsewhere, the surface of the skin is seen to be studded with 
dull-reddish closely packed, flat-topped, often polygonal papules, which 
strongly resemble those occurring in lichen planus, and yet which seem 
to be symptoms of the chronic inflammation present rather than of an 
affection of distinct type. The French refuse to admit that these are 
instances of lichen planus and employ the term “ lichenification” to 
designate the change which is progressing in the skin. It is possible 
that this condition represents a stage intermediate between chronic 


INFLAMMA TIONS. 


291 


inflammation and a specialized dermatosis. In any event, it is necessary 
to distinguish between the two in establishing a careful diagnosis. 

Etiology. The causes of lichen planus are obscure. It is often diffi¬ 
cult to recognize the sources of the disease, but in the majority of cases 
a history of nervous exhaustion can be obtained. Affliction, long- 
continued anxieties, and overwork, especially in cases where mental 
effort is required for its continuance, are frequent causes of this disor¬ 
der. Many patients are notably well nourished and not lacking in 
flesh. In fact, the combination of a fair degree of nutrition of the 
body with nervous exhaustion is to be recognized more commonly in 
patients affected with lichen planus than in any other affection as 
annoying and persistent. 

Other causes cited are: digestive disturbances, malaria, malnutri¬ 
tion, and diseases of the generative organs. Different opinions are 
entertained respecting the frequency with which the two sexes are 
attacked. General experience points to the conclusions formulated by 
Crocker, who reports more cases among (English) women than among 
men, as against the statistics of the Vienna school, which reverse the 
figures. The disease among the nervously taxed of the well-to-do 
classes is encountered more frequently in private practice than among 
out-patients of public charities, who suffer to a greater extent than 
others from cachexia and malnutrition. 

Russell lately reported a case in which the disease followed amputa¬ 
tion of four fingers of the right hand. 

Pathology. Robinson first clearly showed the pathological distinc¬ 
tion between lichen ruber and lichen planus. His observations have 
been confirmed by those of Boeck, Kaposi, Touton, Weyl, and others. 

The first changes noted in the skin are increase in the lumen and a 
sinuous condition of the capillaries supplying the one or two papillae 
concerned in a single papule. The papillae, thus largely filled with 
dilated capillaries, contain also a network of fine connective-tissue 
fibres, and dense, round cells, which proceed to multiply. Later, more 
papillae are concerned in this process and also the epidermis. In 
the places where white points are exhibited granules of kerato-hyalin 
become visible. In some portions of a lichen papule of medium devel¬ 
opment the stratum corneum exhibits an external, dark, narrow, and 
firm layer, and beneath it two to four rows of translucent cells forming 
the stratum lucidum; but in other parts, and when fully developed in 
all parts, the stratum corneum breaks up into definite lamellae, a phe¬ 
nomenon seen in other disorders attended by derangement of the kerato- 
genetic function of the skin. The external layer is dark, when stained, 
and firm; next below it is a wider layer of swollen cells with nuclei 
scarcely visible, or with relics of liberated nuclei; and, still deeper, 
a narrow and solid layer beneath which the stratum lucidum becomes 
visible. 

In Robinson’s sections the horny layer was almost entirely absent 
over the region occupied by the cell-packed papule, below which the 
corium was normal. The rete was centrally hypertrophied, especially 
in the region of the sweat-ducts; its cells above the affected papillae 


292 


DISEASES OF THE SKIN. 


were horizontally flattened, and the granular layer was thickened.. In 
some places it was difficult in consequence of these changes to distin¬ 
guish between the rete and the corium beneath. The cell-infiltration, 
composed largely of embryonic white blood-corpuscles, extended more 
deeply into the corium in the neighborhood of the sweat-ducts. 

Briefly, it appears that the papule of lichen planus is the result of 
a primary hyperemia of the papillae of the corium; a secondary thick¬ 
ening of the lower part of the rete; a tertiary flattening of the papule 
by reason of the resulting pressure, producing thus the appearance of 
umbilication; a proliferation of cells in the granular layer, as a result 
of which the deposit of kerato-hyalin in whitish points or in sheets 
occurs sufficient to produce the clinical peculiarities having that appear¬ 
ance (not due, as Neumann supposed, to changes in the sweat-glands); 
and coloration of lesions due to both vascularization and to escape of 
b lood-corpuscles. 

Diagnosis. The diagnosis rests upon the characteristic shape, size, 
color, grouping, disposition, and umbilication of the papule of lichen 
planus, which are features not found in any other papular disease. 
Thus, in its size, apex, color, and course, the papule of papular eczema 
is quite different from that described above, being brighter, redder, 
more acuminate at the apex, and much more often followed or accom¬ 
panied by catarrhal symptoms. In psoriasis punctata the scales are 
abundant and readily removed; the individual lesions are increased 
rapidly by peripheral extension, far beyond the fullest development of 
the papule of lichen. The papular syphiloderm is not, as a rule, pru¬ 
ritic, not flattened when minute, not polygonal in shape, and not cov¬ 
ered with a closely adherent horny scale, and it always occurs in 
patients where careful investigation discloses other symptoms of the 
disease (mucous patches, adenopathy, etc.). 

The distinctions noted above in connection with lichenifieation of 
patches of chronic inflammation of the skin are not to be disregarded. 

Treatment. Roborant treatment by quinin, the mineral acids, the 
ferruginous tonics, and cod-liver oil, is frequently indicated. Although 
it is claimed that arsenic actually aggravates the disease, there is general 
agreement with Hebra, Wilson, Duhring, and others, in ascribing to it 
the most brilliant results obtained in the treatment of lichen planus, 
results far more consistent than are obtained from the same drug in the 
management of psoriasis. Boeck and Taylor give 15 grains (1.) of 
the chlorate of potassium in 4 ounces (128.) of water, fifteen minutes 
after eating, followed .in a quarter of an hour by 20 drops of dilute 
nitric acid, swallowed in a wineglassful of water. Robinson, in 
generalized hyperemic cases, praises the alkaline diuretics (acetate 
of potassium with sweet spirits of nitre), well diluted after meals; 
Fox regards mercury as valuable in the chronic forms of the disease, 
for which also he administers asafoetida. Koebner has injected both 
pilocarpin and arsenic subcutaneously with success. 

In the way of local treatment Unna has used one part of corrosive 
sublimate, twenty parts of carbolic acid, and five hundred of ben- 
zoated oxid-of-zinc salve; Brocq and Jacquet employ the tepid douche 
for from two to ten minutes once and oftener in the day; Vidal 


INFLAMMA TIONS. 


293 


employs baths of vinegar, 1 litre to the bath; and the external applica¬ 
tion of one part of tartaric acid to twenty of the glycerole of starch; 
Wilson employed a mercurial salve, 2 grains (0.13) to the ounce (32.). 
In all severe cases attended with considerable pruritus frequent baths 
of warm oatmeal or bran-water should be ordered, after which the 
skin should be dried and a Lassar paste applied. When later a stronger 
application is tolerated the paste may be medicated with pyrogallol, 
ichthyol, or the dried sulphate of iron. Tar, thymol, iodin, or chrys- 
arobin may also successfully be employed topically. Weyl employed 
caustic applications, as also one or two parts of beta-naphtol to ninety 
of rectified spirits of wine and ten of glycerin. 

Prognosis. The prognosis is in general favorable, since even cases 
of long standing are usually relieved when the subjects of the disease 
are placed under conditions favorable for recovery. It is always 
to be borne in mind, however, that in individual cases where the 
patient is neurasthenic the eruptive symptoms may persist for years, 
accompanied by intense itching and a consequent teasing of the nervous 
centres. In this class of subjects it is generally well to make a guarded 
prognosis, and to pronounce upon the future with just reserve. 


ECZEMA. 

(Gr. e/c %eo), to boil forth.) 

(Ger., Eczem; Fr., Eczema.) 

Statistical frequency in America, 30 430. 

Eczema is a non-contagious, acute, and more frequently chronic, inflammatory disease 
of the skin, beginning as an erythema, or by the appearance of isolated or grouped 
papules, vesicles, or pustules, occurring either singly, simultaneously, or in succes¬ 
sion, resulting in redness, catarrhal symptoms, scaling, crusting, and infiltration of 
the skin, accompanied by more or less intense itching and burning sensations, and 
leaving, after complete resolution, no cicatrices. 

Symptoms. Eczema is one of the diseases of the skin of most fre¬ 
quent occurrence. In the statistics gathered by medical men it would 
seem to rank first in the order of frequency; but this is only true as 
regards those diseases for which the physician is commonly consulted. 
It is easy to become convinced that acne is a more frequently encoun¬ 
tered affection than eczema, by observing the faces of individuals on 
the streets of any large city, eczema being of more frequent occurrence 
in this situation than upon other parts of the body. Many persons 
are the subjects of acne who never deem it necessary to submit to 
treatment for its relief, and the records of such cases do not figure in 
dermatological statistics. This fact being noted, eczema may be 
regarded as the disease of the skin for which most frequently the 
practitioner of medicine is consulted. By as much as inflammation is 
the commonest accident of other organs of the body, by so much is its 
enveloping organ subject to the same pathological process. 

The surgical signs of inflammation of any given tissue are usually 


294 


DISEASES OF THE SKIN. 


named as increased heat, redness, pain, and swelling. These symptoms 
are essentially those of an eczema, and it will be necessary, in order 
to study this disease intelligently, to inquire how these phenomena are 
modified by the anatomical peculiarities of the organ in this case 
affected. A typical eczema is always betrayed by an elevation of the 
temperature of the body-surface, and by a greater or lesser degree of 
swelling. Redness, in various shades, is also true of the eczematous 
skin. Pain here is represented by a sensation usually of itching, which 
may vary from a slight annoyance to an almost intolerable distress. 
The variation in the sensation which accompauies inflammatory dis¬ 
orders of the skin and other organs is merely due to the fact that the 
skin is exposed to the air, and its increase in bulk is not opposed 
by contiguous parts, as, for example, inflamed bone in contact with 
periosteum, or a pathologically enlarged prostate within its fibrous 
capsule. Inflammation of the inner skin of the body, that of the lining 
membrane of the stomach or of the intestines, is generally characterized 
by the occurrence of increased heat, redness, swelling, and severe pain. 

Inflammation of tissues constituting other organs of the body usually 
terminates either in resolution, in the free production of pus, or in the 
occurrence of gangrene. Likewise an inflammation of the skin may 
terminate either by resolution, or by the free production of pus on its 
surface, the living matter rapidly multiplying as the intensity of the 
process may determine. Gangrene is not a classical result of eczema, 
chiefly because of the freely exposed position of the integument. 

The great variety of expressions assumed by an eczematous disease, 
and the frequent interchange of these, the one for the other, are to be 
accounted for in the same way. The atmosphere surrounding the body 
is but one of many external agencies capable of affecting the skin. 
Thus, it is rubbed and scratched, exposed to the friction of the clothing 
and to the incursions of insects, and is subjected to innumerable injuri¬ 
ous contacts in all the various trades and occupations of life. If the 
inflamed skin could as perfectly be protected from the outer world 
as is the spleen, the history of this affection would be much sim¬ 
plified. 

Clinically, several types of eczema can be recognized. These types 
require separate description. It should not be forgotten, however, 
that each may prove to be not a variety, but a stage of the disease, 
which may speedily give place to yet another. 


Clinical Types and Varieties of Eczema. 

[A] Eczema Erythematosum. In this form of the disease the 
conspicuous symptoms are heat, redness, and swelling, with a variable 
degree of itching, usually less severe than in several of the other phases 
of the malady. The process may begin with acute and intense symp¬ 
toms, soon to be followed by one of the varieties of the disease subse¬ 
quently to be described, or, what is perhaps more commonly the case, 
may continue indefinitely as a subacute or even a chronic affection. In 
color, the skin of the part involved varies from a light to a dark shade 


INF LAMM A T1ONS. 


295 


of red; and inasmuch as the process is more frequently observed in 
middle-aged adults, with darker hue of the integument than in early 
life, the color of the part is frequently noticed to be of a dull shade. 
In consequence of the swelling the affected surface is notably elevated 
above the level of the unaffected contiguous skin, and the line of 
demarcation between the two can more readily be traced than in several 
of the other varieties of eczema. The skin-surface is usually uni¬ 
formly and occasionally symmetrically involved. Lesions, other than 
the erythema, which is the prominent feature of the attack, may not 
be observed, and, as a consequence, from the beginning to the end of 
the disease there may be no history of moisture. But in many cases 
minute poppy-seed- to rape-seed-sized papules become visible on close 
inspection; still more rarely the papules are seen each with a very 
minute vesicular apex filled with a droplet of clear serum. The local¬ 
ities most frequently involved in erythematous eczema are the face, the 
palms, the soles, and the regions about the genitalia, though any portion 
of the body may be affected. Resolution is accomplished after the 
occurrence of a very fine superficial desquamation of the epidermis, or 
by very gradual diminution of the redness and swelling without the 
production of scales. In either event the termination of the process 
is often announced by significant changes in the involved surface, as 
by the fading of color, the appearance of islets of sound skin between 
affected patches, and by perceptible relief in the subjective symptoms. 

Such is the course of typical erythematous eczema. Variations from 
this type, however, are numerous and important. Thus, the disease 
may be limited to a patch as small as the size of a finger-nail, or it 
may extend over larger areas, especially after being subjected to irri¬ 
tation. At times the coloration is irregularly distributed, producing 
a mottled appearance, bright at one point and dark at another, while 
again, as has been indicated, the variety described may coexist with, 
or be followed by, the weeping, excoriation, and crusting which are 
characteristic of other manifestations of eczema. Scratching of the 
part involved produces a change in the symptoms which the skilled eye 
will promptly recognize. Minute superficial losses of tissue are then 
visible here and there upon the surface; the fresher lesions having a 
reddened floor possibly hidden beneath a thin blood-scale, the older 
being surmounted by a light yellowish-red crust. The scratch-lines, 
often recognized elsewhere, are here less frequently evident. 

Like all other varieties of eczema, this form is extremely liable to 
recrudescence and relapse. In advanced life the traces of the disease 
may be visible for years. 

[B] Eczema Papulosum. Under this title are classed all those 
forms which have long been described as Lichen Simplex, Lichen 
Eczematodes, Eczema Lichenodes, etc. It is of the greatest im¬ 
portance that there should be a distinct and more general recognition 
of the fact that in exceptional cases eczema may exist from first to 
last as a dry infiltration of the integument, for there is perhaps no one 
of the various manifestations of the disease that is so frequently mis¬ 
taken and confounded with other widely different affections. 


296 


DISEASES OF THE SKIN. 


The poppy-seed- to grape-seed-sized papules developed in its course 
are usually seated upon a reddened and thickened base, and are them¬ 
selves colored in various shades of red to a dark lurid shade. They 
are usually discrete, though often closely set together, are accompanied 
by a severe form of itching when irritated by scratching, and of all 
eczematous lesions are most apt to be thus irritated. Their summits 
are torn, often to such an extent as to bleed, the blood drying in red¬ 
dish crusts over the involved area, or limited to minute blood-scales 
on the apices of individual lesions. The extent of surface affected 
varies, as is usual in the other varieties, being in some cases largely 
diffused in patches over various portions of the body, or is limited to 
small single patches no larger than the size of a silver quarter of a 
dollar. Such patches, covered with a single or with several groups of 
reddish papules, may continue to torment the patient for long periods 
of time, or, being at one time relieved, may recur with each aggrava¬ 
tion of the malady by the exciting cause. Papular eczema is the dry 
manifestation of the disease, and is thus most frequently noticed upon 
the drier portions of the integument. These parts are the surfaces of 
the limbs, the back of the body, and, in particular, the scrotum. In 
the latter region the lesions, giving a name to this variety of the dis¬ 
ease, are most fully developed. If the moist forms of eczema are 
most frequently seen in early life, it is none the less true that the dry 
forms are the most common in adult life or in advanced years. 

It should not be forgotten, however, that the papules here described 
may develop into minute or larger pustules, or may exhibit minute 
vesicular summits when there is free exudation beneath the surface. 
A patch of papular eczema, where no vesiculation nor pustulation has 
been observed, will, if sufficiently scratched, ooze with moisture, the 
serum escaping from the abraded surface. 

There are, in fact, few scratched eczematous surfaces which will not 
moisten a dry handkerchief applied to the part. This weeping con¬ 
dition attracts the attention of patients themselves, who complain of 
it in describing their symptoms to the physician. A certain species 
of relief for the pruritus is thus obtained; and in aggravated cases 
patients will scratch or rub or otherwise irritate their diseased patches, 
not merely for the purpose of gratifying the intense desire to assuage 
the itching, but also to induce serous exudation for the sake of the 
relief it affords. The secretion when in contact with linen cloths stains 
and stiffens them, very much as seminal fluid leaves its traces upon 
the clothing. 

Resolution of papular eczema is accomplished after the formation 
of scales, the tissues beneath the latter assuming more and more the 
appearance of healthy skin. 

[C] Eczema Vesicttlosum. This variety of the disease, as its 
name implies, is characterized at an early period by the formation of 
minute vesicles. It is a matter of importance, however, to recognize 
the fact that the vesicular, like the erythematous, is but one of several 
manifestations of this singularly protean affection. Long after the 
appearance of the treatises of early English dermatologists, the term 


INF LAMM A TIONS. 


297 


ic eczema” was very generally limited by physicians to the vesicular 
phases of the disease; it is to the Vienna school that we are largely 
indebted for the recognition of the fact that these simultaneous or 
successive features, presented often in the same individual, really 
belong to one and the same malady. To limit the name eczema to¬ 
day to its vesicular variety alone would be to relegate the student of 
diseases of the skin to the misty uncertainties of the first half-century 
of dermatology. 

The clinical features of vesicular eczema are chiefly due to the acuity 
of the inflammatory process present, and to the consequent free exuda¬ 
tion of serum of the blood from the vascular plexus immediately below 
the pars papillaris of the corium. The involved surface usually feels 
at the outset hot, itchy, or particularly sensitive, and soon after be¬ 
comes more or less intensely reddened, the result of hyperemia and 
subsequent exudation which may last for one or for several hours. 
Poppy-seed- to grape-seed-si zed vesicles then become visible on this 
reddened base. The lesions may be closely packed together, or be 
discrete, or may be so abundant as to coalesce, a frequent behavior of all 
vesicular lesions. Each vesicle is filled with a droplet of clear serum, 
imprisoned beneath the most superficial layers of the epidermis. This 
vesicle is readily ruptured, and, if this rupture does not speedily 
occur as the result of accident, the lesion bursts spontaneously, and its 
limpid contents are then poured out upon the surface of the integument. 
The quantity of the fluid thus exuded is in excess of that originally 
contained in the small vesicular chamber. This excess is due to the 
fact that the elevated, macerated, and broken epidermis no longer 
presents an obstacle to the outflow of the serum from the engorged 
vessels beneath. Minute and even large drops of a clear fluid of 
syrupy consistency can be seen forming at the points where the solu¬ 
tion of continuity has occurred. If with a slip of bibulous paper 
the first drop be removed, its place is visibly filled by a second. Crops 
of new vesicles succeed the first, each crop being followed by the train 
of symptoms described. The weeping at many points of the surface 
thus affected is so prominent a feature of the disease that it has led 
several authors to describe eczema as invariably a catarrhal disease of 
the skin. There are, without question, forms of this disease where 
the history is throughout entirely different from that just described, 
where no evidence of discharge can be appreciated from first to last, 
and yet where, by artificial measures, the so-called ‘‘catarrhal” features 
can readily be produced. 

The subjective symptoms of vesicular forms of eczema are more 
or less intense itching and often burning. In very acute forms there 
is considerable soreness, the patient managing the affected part with 
as much care as if it were a fractured limb. In exceptional cases, 
more frequently observed in children, there is sympathetic febrile 
disturbance of a mild grade. 

The discharge from the broken epidermis, whether directly from the 
vesicles or from the vascular elements, dries rapidly when exposed to 
the air, in light yellowish crusts, which are rarely bulky. The extent 
of surface involved is variable, and the contour of the affected patch 


298 


DISEASES OF THE SKIN. 


or patches is seldom well defined, these pathological portions impercep¬ 
tibly shading into the sound skin. The color of the area thus diseased 
varies according to the stage of the process, being at one time of a 
vivid red, at another yellowish, and, when covered with crusts or scales, 
undergoing a corresponding change of hue. Infiltration of the skin 
occurs rapidly, so that when a portion of the affected integument is 
pinched up between the finger and thumb it is found to be thicker 
and less elastic than normal. 

As resolution approaches, all the symptoms described above gradu¬ 
ally decline in severity; the serous discharge diminishes, the redness 
fades, the limits of the involved area become less distinct, the crusts 
loosen aud fall, and beneath the scales which have taken the place of 
the oozing and broken epidermis a new and tender epithelial covering 
is produced. As a rule, for weeks after the process has completely 
ceased, the newly formed epidermis has a slightly reddened and tender 
appearance, though complete resolution is followed by no permanent 
sequels. 

Such then being the typical phases of vesicular eczema, it must not 
be forgotten that clinically the picture may be quite different from that 
described. The types here given are convenient for analysis and 
study, however much they may be commingled and obscured in the 
inflamed integument. Like the erythematous, the vesicular forms of 
eczema may precede the others, and, becoming chronic, may torment 
the suffering patient continuously for long periods of time, or may 
yield, only to reappear at irregular intervals. 

[D] Eczema Pustulosum. This variety of the disease has also 
been termed “ Eczema impetiginodes ” and “ Impetigo eczematodes. ” 
It may originate in one of the other forms of eczema, which form, in 
consequence of the severity or acuity of the process, changes from an 
erythematous, papular, or more commonly vesicular type; or pustular 
lesions may rapidly form at the onset. Usually there is first seen a 
crop of minute vesicles, which, enlarging to the size of that of a coffee- 
bean, become distended with puriform contents. These vesicles either 
accidentally or spontaneously burst, and the fluid with which they 
were distended dries into yellowish-green or darker colored friable 
crusts. In aggravated cases the purulent matter seems to form directly 
upon the involved surface. If the process be long continued, infiltra¬ 
tion occurs, and the itching, which in all varieties of the disorder is a 
characteristic feature, is awakened as an accompanying symptom. 
The itching, however, is rarely of the peculiarly aggravated type 
acompanying the erythematous and papular phases. Pustular eczema 
is most frequently encountered in the region of the head, and in con¬ 
stitutions that do not readily resist the invasion of pus-cocci. When 
existing on the scalp and the face there is most commonly an involve¬ 
ment also of the sebaceous glands, the secretion of which, altered by the 
periglandular inflammation, is added to that naturally produced by the 
exudative process. Singular shades of mixed yellow and green and even 
black, are then to be distinguished in the resulting crusts, which later 
desiccate and fall, leaving a reddened and tender new epidermis beneath. 


INF LAMM A TIONS. 


299 


Pustular eczema, as thus observed, has been described under a great 
variety of titles. Its identity as a form of eczema was first accurately 
distinguished by Hebra, in his experiments in the artificial production 
of the disease upon the skin-surface by the external application of 
croton oil. It has been called Impetigo Figurata, Mellitagra, 
Porrigo Larvalis, and other singular names, which suggest the 
attempts of the early astronomers to designate the constellations by 
the resemblance of each to the figure of an animal. These and many 
other useless terms have finally been dropped from the nomenclature 
of modern dermatology. 

The four types of eczema considered above are, as has been stated, 
sometimes encountered in practice as distinct and unmingled forms of 
cutaneous disease, some of them more commonly than others. To pre¬ 
sent, however, a picture of eczema as it is seen clinically, it must be 
understood that these several forms, useful in the analytical study of 
the disease, often become, in actual observation, well-nigh inextricably 
commingled. “ Observation of the natural course of an attack of 
eczema/’ said Hebra, “ furnishes the most unassailable proof of the 
connection between its various forms. In one case an eruption of 
vesicles begins the series of symptoms; in another, it is preceded by 
the appearance of red scaly patches or groups of papules;, or vesicles 
and papules are developed together, some of the former rapidly chang¬ 
ing to pustules, aud forming yellow gum-like crusts by the drying up 
of their contents.” It is this untiring interchange of features that 
distinguishes all the results of manifold causes operating in nature at 
one and the same time; and it is this which gives the inflammations 
of the human skin, exposed to almost every external influence, such a 
manifold physiognomy. 

Like all other inflammations, eczema may be acute or be chronic. 
Like all others, too, the acute may precede, and the chronic may 
follow, or the reverse may occur; the disorder, originating in subacute 
or insidious forms, may become chronic, and then, as the result of 
fresh or of more severe irritation, may develop into the acutest symp¬ 
toms. Thus the name Eczema Rubrum has been given to the red 
and angry form of the disease, which, because of the free exudation of 
serum from its surface, has also been termed Eczema Madidans. 
In this form the intensely red and wounded integument pours out 
freely upon the surface a thick gummy or syrupy fluid, which, if artifi¬ 
cially re moved, leaves behind it a swollen, angry, and still discharging 
skin; or, being permitted to dry where it has formed, concretes into 
the thick, dark colored and often blood-stained crusts already described. 

Again, the scales which usually form on the eczematous skin toward 
the conclusion of the process just described may prove to be the most 
characteristic feature of the case from the first. Thus on the back of 
the neck an eczematous patch may often be seen, where the skin is 
infiltrated and covered with a stratum of thin, whitish scales, the 
latter having rapidly developed upon an erythematous. surface, and 
continuing for a long period as a scaly disease. It is to this and similar 
forms that the term Eczema Squamosum has been applied. 


300 


DISEASES OF THE SKIN . 


Again, in the regions about the hand the movements of that organ 
often produce fissures or cracks in the inflamed and infiltrated integu¬ 
ment, and to these fissured forms the term Eczema Fissum or Eczema 
Rhagadiforme has been applied. Fissures are observed wherever an 
eczematous disorder has so impaired the elasticity and extensibility of 
the skin that its necessary movements, especially about the joints, tear 
and stretch the thickened integument. It is thus seen not only on 
the hands, but also on the feet and about the ankles, the resulting 
rhagades being, at times, the most painful of all the complications of 
the malady. Occurring upon the bodies and the hands of those who 
are compelled to come into contact with irritating substances, this form 
of the disease finds its severest expression. 

Eczema Intertrigo is a name applied by several authors to that 
form of intertrigo which, surpassing the limits of hyperemia, results 
in an exudative process. Reference is made to this possibility in 
describing the symptoms of Erythema intertrigo. In eczema inter¬ 
trigo the symptoms are usually those of diffused redness of surfaces of 
the skin in close apposition, macerated by previous transudation of 
sweat, and weeping with the serum which oozes from several abraded 
points or patches. 

Eczema Verrucosum, or the wart-like form of the malady, is 
occasionally observed, especially upon the lower extremities, in middle 
life or in advanced years, as the result of long-continued disease. The 
integument becomes thickened and so hypertrophied as to suggest the 
appearance of warts closely packed together in a circumscribed patch. 

Eczema Sclerosum is a form of the disease most frequently 
observed upon the palmar and plantar surfaces, a condition referred to 
in the paragraphs relating to Asteatosis. In eczema sclerosum is pre¬ 
sented a densely thickened inelastic integument, suggesting the condi¬ 
tion of tanned leather, without the occurrence of any of the other 
lesions of eczema described above. As a consequence, the power of 
perfect extension of the digits is impaired. 

Tuberculous Eczema of Nurslings, so called, is a term which 
has been applied to eczematoid eruptions about the mucous orifices of 
the eyes, nose, mouth, and ears, occasioned and sustained by morbid 
conditions of, and serous discharges from, those parts (otorrhea, rhinitis, 
phlyctenular keratitis, etc.), and accompanied by oedema, vesiculation, 
and enlargement of lymphatic glands. The disease is characterized by 
rebelliousness to treatment and chronicity of course. This disorder 
is improperly named, since tubercle-bacilli have not been recognized in 
its lesions; and because the symptoms above enumerated may all be 
present when there is simply systemic nutritive failure and when no 
tuberculosis of other organs is present. 

Eczema Diabeticorum (Fr., Diabetides). A singularlv well- 
defined eczema is to be recognized about the genital organs of both 


INF LAMM A TIONS. 


301 


sexes, but more particularly of women, accompanied by the most atro¬ 
cious pruritus, excoriations produced by scratching, and enormous 
tumefaction of the genito-anal and surrounding integument. The 
local symptoms are chiefly those of eczema erythematosum, the surface 
being, as a rule, destitute of either vesicles or pustules. There are often 
a profuse serous discharge, considerable infiltration, and the production 
of inflammatory nodules over the engorged surface. 

These cases fall within three categories. In the first and rarest the 
patient has saccharine diabetes of long standing, and the parts are 
simply irritated by the passage over them of urine charged with sugar. 
In the second and commoner form there is a temporary glycosuria,, 
either produced by the local eczema or indirectly resulting from the 
latter, and yet due to transitory causes, since both the eczema and 
saccharine urine disappear with relative rapidity when the local treat¬ 
ment is combined with the dietary appropriate for the diabetic. In 
a last group the sugar-fungus (torulci cerevisice) finds a nidus in the 
skin. 

Eczema Folliculorum. Morris first described under this title a 
form of eczema which he says begins as an inflammation of hair- 
follicles. Each inflamed follicle projects from the surface in the form 
of a reddened papule about which the skin becomes byperemic. As 
the process spreads centrifugally by the involvement of adjacent fol¬ 
licles, the centre undergoes involution, with desquamation, and a grad¬ 
ual change in color from red to yellow. This condition is found most 
frequently on the extensor surfaces of the legs and the arms, in mul¬ 
tiple, scattered patches. The itching may be intense. This form of 
eczema is obstinate, and usually recurs. Morris considers it parasitic 
in origin and allied to sycosis. 

Eczema Parasiticum. Under this title is included a large number 
of cases the exact relations of which to the recognized types of the 
disease are still indeterminate. It is well known, for example, that the 
surface of the human body in health is the habitat of an enormous 
number of different parasites which are, for the most part, harmless or 
are effective as agents of disease only under certain specially favorable 
conditions of the body. Cultivation-experiments with the flora found 
on the eczematous skin have revealed a large number of parasites (mostly 
of vegetable origin) which together, if not singly, may be effective in 
producing some of its distinctive features. According to Unna, eczema 
is in these cases a chronic parasitic catarrh. 

Eczema Marginatum is that form in which the parasite pro¬ 
ductive of ringworm is the effective cause of the disorder, and, 
according to Unna, eczema seborrho'icum is to be included in the 
same class. 

Eczema Seborrhoicum is described under the title of dermatitis 
seborrho'ica . 


302 


DISEASES OF THE SKIN. 


Eczema occurs also with acute and chronic manifestations; these 
are, as has been seen, interchangeable conditions, the types of which 
possess, however, a clinical distinctness. 

Acute Eczema. 

An acute attack of eczema is ushered in by malaise, chilliness, or 
the recognized symptoms of the febrile state. With or without these 
prodromata the affected portion of the skin-surface becomes the seat 
of a burning sensation which is soon succeeded by redness and swelling. 
This tumefaction may occur upon one or upon several portions of the 
body at the same moment of time, and the disease throughout be 
limited to a single area or to several spaces; or it may extend from 
one to other or all regions. This extension may proceed by continu¬ 
ous development of the disease along the surface, or an eczema of 
the thigh may suddenly be followed by an eczema of the face, and 
this by au eczema of the scrotum. According to Kaposi, extension 
of eczema by the last-described course is due to the extraordinary sen¬ 
sitiveness of the skin when involved in an acute attack, in conse¬ 
quence of which the slightest friction, or even reflex irritation of the 
blood-vessels, produces a new focus of the disease at a distant point. 
This consideration is of special importance. Patients will frequently 
point to an acute eczema upon several portions of the body widely 
separated from one another, and will urge this as an irrefutable argu¬ 
ment in favor of the fact that they suffer from some “ poison in 
the blood. ” 

The tumid and erythematous surface above described soon assumes 
the features of either papular or vesicular eczema, which need not be 
again detailed. In this manner the evolution of the disease occurs, 
and may continue for weeks, the patient, if unrelieved, being tor¬ 
mented by the itching, and, if the disease be extensive, being prevented 
from attending to his usual vocation. Acute eczema of severe grade 
will frequently prostrate a strong adult, confining him to his bed¬ 
chamber and often to his bed. When there is a simultaneous febrile 
process the emaciation and adynamia are proportioned to its severity. 
Weeks and even months may elapse before recovery can be pronounced 
complete, subacute patches of the disease lingering here and there upon 
the surface, crust-hidden, scale-covered, occasionally oozing from recru¬ 
descence of symptoms. Recovery, even when complete, leaves the 
patient, it should never be forgotten, with a skin sensitive to irritation 
and more prone to a fresh attack of the disease than one long virgin of 
an inflammatory process. 

Such is the course of an attack of acute eczema of severe grade. 
Needless to say that a circumscribed patch of the skin may exhibit all 
the features of vesicular eczema in an acute form, and, under the influ¬ 
ence of an appropriate treatment, may satisfactorily be relieved in the 
course of a few days. Lastly, acute eczema may be followed by chronic 
forms of the disease, the one passing into the stages of the other by 
scarcely definable gradations. 


INF LAMM A TIONS. 


303 


Chronic Eczema. 

The symptoms and pathology of chronic eczema are largely those of 
the acute form of the disease. The chief differences to be noted relate 
to diminished intensity of the inflammatory action, or marked tendency 
to recurrence and persistence of the process, and a preponderance of 
scaling and infiltration as contrasted with the active secretion and 
crusting of acute phases. It is important, however, to remember that 
chronic eczema is not only the frequent sequel of such acute phases, 
but is particularly prone also to recurrent exacerbations of acute grade, 
during which the serous discharges, consequent crusts, and angry 
aspect of the affected surface do not fail to reappear. The itching so 
characteristic of the malady in all its manifestations is here also a 
tolerably constant symptom. 

Chronic eczema may involve a limited region of the skin, or may 
invade the entire surface of the body from the head to the feet. Rarely 
thus generally developed, it is more frequently observed upon circum¬ 
scribed patches of the integument, as, for example, the scrotum or 
the flexor surface of a joint, in which situation it may Huger for years 
or even for a lifetime, now better and now worse, or disappearing for 
brief periods only to return with each recurrence of its cause. 

Etiology. Eczema is a disease of both sexes and of all ages. Ten¬ 
dencies to all disorders of the body may be inherited, but eczema, as 
such, is not an inherited disease. It is noted elsewhere that eczema, 
in certain cases, is due to parasites; but for the majority of cases it 
should, nevertheless, be classed with non-contagious affections. 

In many cases no cause of eczema can be discovered beyond the 
causes which operate exclusively within the skin-organ and which are 
proper to itself. These causes are necessarily obscure, and will so 
remain until we are in possession of far more knowledge than possessed 
-at present as to the complex and inscrutably delicate processes by which 
innervation, nutrition, and new formation of the living matter of the 
skin are both conserved and impaired. The autonomy of the integu¬ 
ment must be conceded to the extent recognized in other organs of the 
body. There are diseases of the liver that are neither referred to the 
blood, to the nerves, nor to the action of poisons. There are diseases 
of the heart that are induced by neither rheumatism nor syphilis. 
When the etiology of the disorders of all the viscera is perfected, that 
of the skin displaying the lesions of eczema will assuredly be more 
distinct. 

These remarks are justified by clinical facts. Eczematous affections 
occur in individuals who are in every respect superb examples of 
good health, and whose bodies, after the most thorough and careful 
examination, fail to reveal for the disorder either an external or internal 
cause. Eczema occurs also in persons who are affected with every 
form of bodily ailment: those suffering from acute and chronic disor¬ 
ders of every viscus and system of the body, and even those affected 
with other disorders of the skin. This is only what a study of estab¬ 
lished facts would suggest, having in view the probable proportion of 


304 


DISEASES OF THE SKIN. 


eczematous attacks in every thousand individuals. Such coincidences 
would, however, scarcely furnish a satisfactory etiological basis for the 
disease, unless a certain degree of constancy between eczema and these 
disorders could be established. Thus, eczema is often seen in patients 
affected with rheumatism, gout, dyspepsia, malaria, obstinate constipa¬ 
tion, anemia, scrofula, and pulmonary disorders, a list of affections 
exhibiting surely very wide pathological differences. Yet he would 
prove to be a physician of limited experience who could not select 
from patients under his own observation twenty individuals affected 
with any one of the diseases named, no single person of the entire 
number having ever exhibited symptoms of eczema. If figures alone 
were to decide the question, these, and a larger list of maladies which 
have been named in similar connection, would be excluded in the 
study of the etiology of the disease. 

As predisposing causes, those operating by inducing systemic debil¬ 
ity, many if not all the diseases named above, may be effective. In 
this way, chlorosis, albuminuria, diabetes, tuberculosis, struma, gout, 
rheumatism, uterine disease, dyspepsia, hepatic disease, constipation, 
and other gastro-intestinal disorders may lay the foundation for a per¬ 
sistent eczematous attack. In a similar way it is possible that a pre¬ 
disposition to this malady may be inherited, bub as distinguished from 
all the diseases known to be transmitted by heredity, no child was ever 
born into the world with an eczema. 

Eczema seems, in exceptional cases, to bear some relation to spas¬ 
modic asthma, sometimes coexisting with that disease in one person, 
or its attacks alternating quite regularly with asthmatic paroxysms. 
This relation may be due to the exquisite sensitiveness of the skin, 
the mucous membranes, and the nervous system exhibited in some 
patients. 

The so-called u internal causes” of eczema must, for reasons given 
above, be considered for the most part as either coincidences or as 
conditions favoring the development of diseases in general, eczema not 
excepted. By interference either with innervation, nutrition, develop¬ 
ment, excretion, or the* performance of the important functions of the 
body, as well as by reflex irritation of the surface, these internal 
causes operate by inviting, aggravating, or prolonging an eczematous 
attack. Among such predisposing conditions may be named not merely 
the diseases enumerated above, but also, as physiological states, preg¬ 
nancy, lactation, and dentition; as associated with the habits of life, 
occupations necessitating inordinate fatigue of body or of mind, espe¬ 
cially with the exclusion of sunlight; and lastly, as originating in the 
irritative action upon the mucous surfaces, of substances foreign to the 
body, dietary and medicinal articles capable of exciting cutaneous 
rashes; intestinal parasites; and instruments inserted and fluids injected 
into the mucous canals, as, for example, the male urethra. 

This much premised, it should be added that nearly every phase of 
eczema can artificially be produced upon the surface of the skin by the 
action of external irritants. Several authors, notably those of French 
nationality, take exception to this view, they claiming that the induced 
disease in such instances is an artificial dermatitis, but they fail to 


INF LAMM A TIONS. 


305 


point out the distinctive objective differences between such dermatitis 
aud eczema. They content themselves with observing the subsequent 
evolution of the malady, and pronounce that to be an eczema which 
fails to respond promptly to treatment, and that a dermatitis which is 
capable of speedy relief. The climax of such absurdity is reached 
when they are shown obstinate cases of eczema of an artificial origin, 
and the response is that the induced dermatitis gave rise to an eczema 
in a predisposed subject. 

A step further, and one is in position^o estimate the approximate 
value of the etiological factors in eczema. The large majority of all 
generally recognized and externally operating causes of the complaint 
fail to have such an effect in the mass of individuals. Whether any 
of them is necessarily followed by the disease is open to some question. 
Even the poison-ivy, a fertile source of the disorder in susceptible indi¬ 
viduals, will fail to influence others. The late and eminent Professor 
Boeck, of Christiania, when he last visited America rubbed the tender 
leaves of this plant over his hands and face in repeated efforts to pro¬ 
duce the disease in his own person, and utterly failed of the desired end. 

Respecting the numerous agencies operating thus externally and 
capable of producing the disease under consideration, they can all be 
referred to either solar light and heat, to contact with foreign bodies 
in various fluid or solid states, to toxic agencies of a widely differing 
nature, to traumatisms in varying degrees, and to the action of para¬ 
sites. Many of these agencies co-operate, some include others, and 
some become effective by aggravating a disease which others have 
engendered. The reader is referred to the chapter on General Etiol¬ 
ogy for fuller consideration of this subject It will be sufficient to 
note here that acids, alkalies, antimonial and mercurial compounds, 
mustard, sulphur, castor-oil, capsicum, arnica, turpentine, chloroform, 
ether, alcohol, and a long list of other medicaments are capable of 
producing eczema when applied to the skin externally. The same 
statemeut is true of articles manipulated in many of the trades—those, 
for example, handled b}^ the grocer, the baker, the confectioner, the 
seamstress, the ink-manufacturer, the mason, the cook, the gardener, 
the laundress, the painter, the dyer, the printer, the tobacconist, and 
the chemist. Then, too, the eczema of the person exposed to severe 
cold, or to intense solar light and heat aided by reflection from water, 
or even by excessive artificial heat, as the fire of a furnace, illustrates 
the action of other causes named. Pressure and friction effects are 
exhibited in the eczema produced by contact with gaiters, cuffs, trusses, 
saddles, crutches, and corsets. 

Scratching is a fruitful cause of eczema when the skin is affected 
with pruritus as a distinct disease, or as a symptom of other cutaneous 
disorders. Thus, it is efficient in urticaria, scabies, and the prurigo 
of Hebra; in the skin bitten by lice, insects, bedbugs, and fleas (which 
even without such interference are capable in many cases of inducing 
the disorder); and in the lower extremities, when the skin here is 
distended by varicose veins. 

Water is capable of exercising an injurious effect upon the skin to 
the extent of producing an eczema, whether it proceeds from the sudo- 

20 


306 


DISEASES OF THE SKIN. 


riparous glands in an excessive exudation of sweat which is not duly 
removed by ablution, or is applied externally as a fluid in excessively 
cold or hot temperatures, or in the vapors of the popular Turkish and 
Russian baths, or, yet again, be rendered irritating by saline or other 
constituents. 

The external sources of eczematous trouble named above should be 
regarded simply as suggestive illustrations. It should be borne in 
mind that every contact with the external world, sufficiently severe or 
prolonged to awaken the resentment of the healthy skin, may be fol¬ 
lowed by the protest of the latter in the shape of an eczema; and the 
same may be true when even the most trivial external accidents occur 
to the sensitive skin of certain individuals particularly prone to the 
disease. 

The forms of eczema due to parasites are described under Parasitic 
Eczema. Some of these parasites are derived from the animal and 
some from the vegetable kingdom. 

Pathology. The pathological changes in eczema are those of inflam¬ 
mation of the skin, varying somewhat with the acuteness or chronicity 
of the process, aud with the character and career of the exudate fur¬ 
nished in each expression of the disease. In all cases there is, first, a 
circumscribed or diffused hyperemia of the affected part followed by 
congestion, exudation of serum, diapedesis of white blood-corpuscles, 
and proliferation of connective-tissue cells. 

The process begins in the corium, and usually in the papillary layer, 
from which it extends to the epidermis and in exceptional cases inward 
even to the subcutaneous tissue. 

The papillae are enlarged, their fibrous bundles swollen, their vessels 
dilated, and the connective-tissue cells increased in size and number. 
This increase in the number of cells in the corium is due largely to the 
presence of migrated cells, though there is undoubtedly some prolifer¬ 
ation of the connective-tissue cells, which is most marked in chronic 
cases. The exudate may be abundant and even produce marked swell¬ 
ing of the surface, as in some forms of vesicular and pustular eczema, 
or the infiltration may be slight, as in the papular type. The exuded 
serum filtrates between and separates the rete cells, many of which are 
in consequence destroyed and form small cavities (vesicles) in the upper 
part of the rete, which are filled with fibrin, coagulated serum, nuclei, 
and fragments of cells. Or the exudate may simply raise the horny 
layer from the rete to form vesicles or even bullae. If these cavities 
become filled with leucocytes, pustules result. 

In eczema rub rum the horny layer is raised from the rete and de¬ 
stroyed without true vesicle-formation. The rete is thus exposed 
directly to the air, or is partly covered by an amorphous coating of 
dried serum and degenerated cells. In chronic cases the cell-infiltration 
and cell-proliferation in the deeper layers of the rete and of all parts 
of the corium are very marked. 

In chronic squamous eczema there are proliferation and exfoliation of 
the cells and dilatation of vessels in the corium, but the rete is only 
slightly changed. 

When the process continues for some time the multiplication of the 


INF LAMM A T1ONS. 


307 


cells and of the connective-tissue bundles in the corium becomes very 
marked, producing the thickening of the skin so characteristic of 
patches of chronic eczema. In these cases the papillae are larger than 
normal, the vessels of the corium are dilated and surrounded by con¬ 
nective-tissue cells. The process may extend to the subcutaneous fatty 
layer, which then loses much of its fat, becomes dense and attached to 
the skin. Lymphatic obstruction with elephantiasic changes may 
follow. In these cases the sebaceous and coil-glands and the hair- 
follicles may be partially or entirely destroyed by undergoing degen¬ 
eration and atrophy. 

The fluid exuded in eczema, whether taking part in tumefaction of 
any portion of the skin, as in vesiculation, or in a free discharge from 
the surface, is always identical. It is a yellowish-white, sticky and 
syrupy liquid, feebly alkaline in reaction, depositing albumin in 
abundance when treated by heat and nitric acid, and exhibiting the char¬ 
acteristic features of the serum of the blood under the microscope. 
Exposed to the air, it desiccates in light yellowish to brownish, friable 
crusts resemblng honey or gum. 

Increase in the pigment-particles distributed to the epithelia of the 
rete is characteristic of the chrouic forms of eczema, and more espe¬ 
cially of those in which the circulation is somewhat impeded by the 
influence of gravity, as, for example, in the lower extremities. This 
increased pigmentation is true, however, of all diseases accompanied 
by an augmented afflux of blood to any part of the body, as, for ex¬ 
ample, over the surfaces of joints to which for many years stimulating 
embrocations have been applied. 

The elevation of the body-temperature in the inflamed skin is some¬ 
what proportioned to the rapidity of the process. In acute eczema 
such elevation may exceed 105.5° F. (41° C.), while in chronic eczema 
it can scarcely be appreciated. 

Diagnosis. Eczema in its manifestations is such a protean disease 
and is, moreover, of such frequent occurrence, that it is necessary to 
establish a differential diagnosis between it and a large number of other 
cutaneous disorders. The more important of these disorders are named 
below in alphabetical order for convenience of reference, the distinctive 
differences of each being briefly appended. It must be remembered, 
however, that the identity and characteristics of eczema are made clear 
only after a close study of all its features, and that this is the surest 
basis for an accurate diagnosis in every case. 

Acne. Acne occurs chiefly on the face, the neck, and the back of 
the trunk, and its pustular forms might be mistaken for eczema of the 
same localities. But pustular acne is usually accompanied by a deeper- 
seated infiltration than the similar lesions of eczema, and this infiltra¬ 
tion is also generally limited to the sebaceous glands or the periglan¬ 
dular tissue. In eczema the itching is often severe, while in acne the 
subjective sensations are those of heat or burning. Comedones inter¬ 
mingled with the pustules of acne will aid in distinguishing the two. 

Erythematous eczema of the face is to be distinguished from acne 
rosacea by the more generalized infiltration of the former, its produc- 


308 


DISEASES OF THE SKIN. 


tion of itching, and its greater diffusion over the face; while acne 
rosacea is more often limited to the cheeks, nose and brow, and to the 
region adjacent to these parts. The patch of erythematous eczema is 
“ hot,” that of acne rosacea is cold, to the touch. The former is seen 
in infancy, the latter is rare in that period of life. Acne rosacea in 
many cases is also readily distinguished by the development of visible 
blood-vessels in the skin of the cheeks or the nasal region. Lastly, in 
erythematous eczema, the eyelids are apt to suffer, while in acne rosacea 
this is the exception. In severe forms of acne the subepidermic pus- 
formation and the resulting scar will prove significant. 

Dermatitis. Dermatitis, of artificial origin, is to be distinguished 
from idiopathic eczema rather by its history than by special differences 
in the appearance or evolution of the lesions. In many cases the two 
affections are indistinguishable. A history of traumatism or of the 
external application of irritant or of toxic articles will often serve to 
distinguish the two. When the dermatitis has been produced by an 
externally applied irritant the resulting inflammation of the skin will 
often exactly outline the area of contact. Dermatitis of artificial pro¬ 
duction is usually sudden in its onset, the date of which will nearly 
correspond with the time of operation of an exciting cause. The sub¬ 
sidence of the symptoms after the withdrawal of the cause will also point 
to the nature of the affection. Eczema is also much more capricious 
in its distribution and career than dermatitis. 

Erysipelas. Erysipelas is generally accompanied by febrile symp¬ 
toms; in many cases bullae appear. The affected surface is reddened, 
much more swollen than in eczema, and it exhibits besides a character¬ 
istic shining appearance, which is always absent in erythematous 
eczema. The line of demarcation between the affected and unaffected 
portions of the skin is usually distinctly defined in erysipelas, ill-defined 
in eczema. Erysipelas spreads from one point to another with a 
rapidity which is never noticed in eczema; the latter disease, moreover, 
exhibiting under a lens its minute papules or vesicles. In eczema also, 
when occurring upon the face in the erythematous form, the scalp is 
usually spared, while erysipelas teuds to invade the scalp and the 
regions covered by the beard. 

Erythema. Eczema is to be distinguished from the forms of 
erythema which are due to hyperemia only, by the presence of an 
inflammatory process. The erythema simplex which advances to exu¬ 
dation at once transgresses the artificial line of distinction between 
the purely congestive and the purely exudative disorders. It must, 
therefore, be remembered that many eczemas begiu as erythemata, and 
that, clinically, the latter may represent but a stage in the morbid 
process. The discharge in erythema intertrigo results from imprisoned 
or from chemically altered sweat, and will not stiffen linen, as does 
the serous exudation of vesicular eczema, for example. Erythema 
multiforme, an affection really on the border-line between the two 
pathological classes here sought to be distinguished, will be recognized 


INFLAMMA TIONS. 


309 


by the absence of severe itching, and the recurrence of the disorder 
at certain special seasons of the year; while Erythema papulosum, E. 
tuberosum, and E. nodosum, display solid elevations of the skin- 
surface much exceeding in size the minute lesions of papular eczema. 

Herpes. Eczema is so associated with the occurrence of a vesicle 
in the minds of many that other vesicular disorders are apt to be 
confounded with it. But in herpes febrilis the vesicles are usually 
grouped about the mucous outlets of the body, and when actually 
under observation they exceed in size the minute and transitory lesions 
of vesicular eczema. In herpes zoster, with the limitation of the erup¬ 
tion to one side of the body, there is also a history of precedent neuralgic 
pain. The subjective sensation is a decided burning rather than itch¬ 
ing, and there is a possibility of the subsequent production of scars. 

Impetigo and Impetigo Contagiosa. In these forms of disease 
pustular lesions are usually isolated, do not spring from an infil¬ 
trated surface where other lesions may be visible, and are unaccom¬ 
panied by the intense pruritus which is characteristic of eczema. The 
pustules, moreover, are larger, and the resulting crusts, as a rule, are 
bulkier and darker colored than those in eczema. Again, in pustular 
eczema the cutaneous affection usually occurs in one or more patches, 
while in impetigo a dozen or more isolated pustules may be irregularly 
scattered upon the entire surface of the body. In the contagious form 
of impetigo there may be a history of the extension of the disease 
from one member of a family to another. 

Lichen Pl4NUS. In this disorder the papules very rarely become 
vesicular as they do in eczema; while those of eczema never assume in 
any stage the peculiar sepia-tinted hue of the similar lesions of lichen 
planus. The latter lesions, moreover, are often umbilicated, are chronic 
in development, are frequently symmetrical in disposition, and are 
scaly at the flattened summit. 

Lichen Buber. In lichen ruber the dull red, non-excoriated pap¬ 
ules, covered with minute scales, and unattended by severe itching, 
could scarcely be mistaken for the vivid, angry, and scratched papules 
of eczema, which, moreover, are often accompanied by secretion from 
the surface. When the scales covering the patches of coalesced papules 
in lichen ruber are removed, the orifices of dilated hair-follicles become 
visible. This dilatation is never true of papular eczema. But the 
important symptoms of a grave disease in lichen ruber, such as maras¬ 
mus and the indications of a fatal termination, will not fail to attract 
attention. 

Lupus Erythematosus. Lupus erythematosus greatly resembles 
certain forms of squamous eczema. The great chronicity of lupus; the 
firm attachment of the scales; the symmetrical distribution of many 
patches upon the face; the association of some forms of the disease 
with the sebaceous glands; the definite border of each involved area; 


310 


DISEASES OF THE SKIN. 


and, above all, the discovery of a cicatrix where the morbid process 
has been unchecked will sufficiently distinguish the disorder. In 
eczema, there is usually itching, often vesiculation, more rapid exten¬ 
sion of the borders of a single patch, and scales much more loosely 
attached, thau in erythematous lupus. The scales of eczema are never 
provided, as is lupus erythematosus, with stalactitiform plugs on the 
inferior surface. 

Lupus Vulgaris. Lupus vulgaris is readily distinguished from 
eczema by its more chronic career, by its larger papules and tubercles of 
dark reddish-brown hue, and by every one of its destructive processes, 
none of which is ever recognized in eczema. 

Pediculosis. As eczema is often induced by lice upon the head, 
the pubes, or the clothing, it is always necessary to exclude the operation 
of such causes both for diagnostic and therapeutic purposes. Eczema, 
limited to the pubic region or existing there, and elsewhere only about 
the axillae, should suggest careful examination of the skin and the 
hairs for the discovery of the crab louse. As for the pediculus cor¬ 
poris, it should be the rule of the physician, invariable and never 
to be forgotten (whatever the social position or refinement of his 
patient), to search for evidence of the parasite upon the under surface 
of the clothing worn next the skin, at the instant of its removal and 
while the patient supposes him to be busied with the inspection of the 
cutaneous lesions. The excoriations produced by scratching wounds 
inflicted by body-lice are usually out of all proportion to the amount 
of skin disease present; and this excoriation is the most significant of 
all symptoms next to the discovery of the corpus delicti. Head-lice 
may precede or may follow eczema of the scalp, but either they or their 
ova (nits), clinging in numbers to the hairs, will be visible to him who 
looks carefully for them. 

Pemphigus and Pityriasis Rubra. The large isolated bullae of 
pemphigus vulgaris are never seen in eczema. In pemphigus foliaceus 
the lesions are succeeded by the formation of pastry-like crusts, serous 
exudation, considerable soreness, and the eventual production of an 
extensive and usually fatal exfoliative dermatitis. Marasmus more 
or less rapidly ensues, while, as a rule, itching and infiltration are 
not present. The disease known as “pityriasis rubra ” is equally 
rare and fatal, and, though unattended with the production of bullae, 
is characterized by an abundant epidermic exfoliation; itching and 
infiltration being either entirely wanting or insignificant in comparison 
with the other symptoms present. The scales, too, are papery, large, 
and thin; there is no vesiculation and moisture, and little, if any, 
infiltration of the skin. The integument is, moreover, of a uniformly 
reddish hue. Both pemphigus foliaceus and pityriasis rubra are par¬ 
ticularly liable to be complicated with chills or with uncontrollable 
diarrhea. Without question, many of the reported cases of so-called 
“ pityriasis rubra ” are instances of squamous eczema. Here the local¬ 
ization of the disease to one or more patches upon the body, the severe 


INF LAMM A TIONS. 


311 


itching, and the distinct infiltration of the patch point to the ecze¬ 
matous character of the disease. Observation of such patients will 
finally convince the observer, in many cases, that there is occasional 
weeping from the surface. 

Pityriasis Rubra Pilaris. Often this disease resembles in a 
high degree, and it may indeed be confused with, the squamous forms 
of eczema. In general there are not found in eczema characteristic 
lichenoid papules formed about the hair-follicles, with their hyper- 
keratinized cap sheathing the follicular orifice, over the extremities 
and especially over the dorsal aspect of the fingers. In eczema there 
are usually distinct marks of scratching that may wholly be wanting 
in pityriasis rubra pilaris; and the latter has distinctly a more chronic 
course in most cases. 

Prurigo and Pruritus. In the prurigo of Hebra, a disease ex¬ 
ceedingly rare in America, there are infiltration, intense itching, and 
numerous minute papules. But this disease usually occurs within a 
year or two after birth, and lasts for a lifetime, extending generally 
over the greater part of the body, sparing only the palms and soles 
(which eczema does not), and is accompanied by inguinal adenopathy. 
In pruritus, often confounded with prurigo, there is itching without 
disease of the skin save that induced by the nails to relieve the sensa¬ 
tion. Hence, pruritus without scratching will not reveal a cutaneous 
disease, while pruritus with scratching will exhibit either excoriations, 
or an eczema induced by the attacks made upon the skin. The latter 
condition, however, is rarely noted. The distinction will be clear 
when it is remembered, first, that pruritus is usually of a paroxysmal 
character, being worse regularly at certain hours or seasons; second, 
that pruritus not originating in a cutaneous lesion, but indirectly pro¬ 
ducing the latter by the medium of the finger-nails, never exhibits as 
much cutaneous excoriation as the skin bitten by lice or attacked with 
eczema. The impressive features here are always the disproportion 
between the complaint of the patient and the visible symptoms, and 
the vast preponderance of all lesions when the skin has been scratched 
in those regions of the body most accessible to the hands, such as the 
anterior faces of the limbs, the genital region, the lower belly, etc. 

Psoriasis. Psoriasis and eczema in typical forms are distinct. 
Variations from type from one to the other furnish many obscure cases. 

The following are the chief diagnostic points in psoriasis: sharp defi¬ 
nition of contour of patch; abundance and lustrous hue of the scales; 
absence of moisture; vascularity of tissue beneath the scales; sites 
of election on posterior aspect of the trunk and extensor surfaces 
of limbs; chronicity in course; uniformity of lesions; and usually 
absence of itching. In eczema there is an ill-defined contour; usually 
scanty scales not having a nacreous hue; a preference for the flexor 
surfaces of the extremities, though the disease may occur in any portion 
of the body; generally, at some period in its course, a history of mois¬ 
ture; polymorphism, as regards lesions; and a marked intensity of 


312 


DISEASES OF THE SKIN. 


subjective sensations. Upon the scalp psoriasis is particularly apt to 
extend beyond the hairy border in a fillet stretching across the upper 
portion of the forehead, thence irregularly down in front of the ears; 
while eczema of the face, when the scalp is also invaded, departs boldly 
from the hairy parts to the lower forehead, the lips, nose, cheeks, or 
chin, regions which are relatively spared by psoriasis. Finally, the 
two diseases, in doubtful cases, will generally be distinguished by 
carefully searching the entire surface of the body, upon some part of 
which in psoriasis there will usually be discovered a tell-tale patch 
of typical appearance. 

Scabies. Scabies is really an art ficial eczema induced by the 
incursions of the acarus scabiei , and its lesions are thus those of 
eczema. In scabies, however, the pruritus is intense and the several 
papules, vesicles (these much less closely set than in eczema), and 
pustules are more likely to be coincident than successive, exhibiting 
thus the multiformity characteristic of the disorder when produced 
by the parasite. The discovery of the presence of the parasite, espe¬ 
cially if there be a history of contagion, and the localization of the 
disease in its sites of preference, will at once determine the diagnosis. 
Scabies never attacks the scalp. Its sites of preference are, in both 
sexes, the fingers, hands, wrists, and axillae; in women, the breast 
and the nipple; in men, the penis; and, in children, the buttocks. The 
presence of the acarian furrow, if the disease has existed for some 
time, and the appearance of minute blackish dots or points upon or 
about the lesions, usually suffice to establish the real nature of the 
disease. 

Scarlatina. This disease can only be confounded with certain of 
the varieties of eczema exhibiting an erythematous type. In scarlet 
fever, however, the elevation of body-temperature, the appearance of 
the tongue and fauces, and frequently the history of contagion, serve 
to distinguish the disease. The peculiar ‘ ‘ boiled lobster ” appearance 
of the skin, and its symmetrical distribution over the surface of the 
body, with gradual extension from the head and trunk to the lower 
extremities, are never seen in eczema. The finger-nail drawn across 
the skin of the patient affected with scarlet fever is usually followed 
by the appearance of a whitish line, which, corresponding with the 
impression made with the nail, is highly characteristic of the eruption. 
Lastly, a generalized eruption of eczema will never disappear with the 
rapidity of the scarlatinal rash. 

Seborrhea. Seborrhea and eczema mav coexist, either disease pre¬ 
ceding the other. Typical forms of each are readily distinguished. In 
eczema there are infiltration and much consequent itching; in sebor¬ 
rhea, there is neither. The scales of seborrhea are more voluminous 
and greasy than those of eczema, are freely shed from the surface, and 
are seated usually upon an integument of scarcely altered hue; in 
eczema the scales are dry, scanty, and more firmly attached to a usually 
hyperemic base. Seborrhea of the hairy parts is generally symmetri- 


INF LAMM A TIONS. 


313 


cally diffused; eczema, though occurring with ill-defined contour, is 
rarely as symmetrical, usually more acute, and is seldom followed by 
alopecia. Upon non-hairy portions of the body the same distinctions 
can to a great extent be observed. The crusts of eczema removed 
from the face generally disclose beneath them an oozing surface, while 
the under surface of these crusts never exhibits the stalactite-like pro¬ 
longations which pass from the under surface of seborrheic crusts into 
the patulous orifices of the excretory ducts of the sebaceous glands. In 
eczema seborrho’icum the features of both diseases are almost completely 
fused. 

Sycosis. Both the so-called u parasitic ” and the “ non-parasitic ” 
forms of sycosis are limited to the region of the beard, while eczema 
of the hairy portions of the face will usually be found to affect other 
parts. In eczema the itching is severe, the exudation spreads beyond 
the limits of the beard, and the discharge is characteristic; while in 
both forms of sycosis there is less oozing and the subjective symptoms 
are trivial. The discovery of the parasite in the root or the shaft of 
the hair will at once distinguish the hyphogenous forms of the disease. 
In sycosis each pustule is perforated by a hair. Eczema limited to 
the region of the beard is even rarer than the two varieties of sycosis. 
The circumscribed indurations and tuberculations of the affection pro¬ 
duced by the trichophyton, as well as the looseuingof the hairs in their 
follicles, constitute further distinctive differences. 

Syphilis. There can be no question that several syphilitic erup¬ 
tions resemble certain forms of eczema. In the eruptions due to syph¬ 
ilis, however, there is usually a history of infection; of involvement 
of the glands and mucous surfaces; of ulceration aud cicatrices in 
advanced periods; and, especially in the case of infants with an eczema¬ 
like eruption, of a history of snuffles. It should always be remem¬ 
bered that the intense itching of eczema is characteristic of no one of 
the syphHides, and that the latter are remarkable for their tendency 
to occur with a circular or partially circular outline, and to be covered 
with bulky crusts of an offensive odor. A point particularly worthy 
of note is suggested in the diagnosis of chronic eczematous affections. 
A syphilitic eruption limited for an equal period of time to one locality 
will often ulcerate or exhibit evidences of repair by scar-tissue, no such 
results occurring in eczema. 

Syphilis of the palms and soles exhibits very distinctly limited out¬ 
lines in the usually circular, circumscribed, and deeply infiltrated 
patches present, which are often symmetrical in development, or are at 
least situated on both sides of the body, even if more fully developed 
upon one limb. Syphilitic pustules upon the scalp usually rise above 
well-defined ulcers. Syphilitic eruptions encircling the mouth in chil¬ 
dren are less angry-looking and formidable than those of severe eczema 
of the same region, being often made up of flattened papules, moist 
or scaling, grouped in circles about the lips, with mucous patches at 
the angles. 


314 


DISEASES OF THE SKIN. 


Tinea Circinata. In ringworm there should be a history of con¬ 
tagion, microscopical discovery of the vegetable parasite, distinct con¬ 
tour of all separate patches, and absence of marked subjective sensations 
and of discharge. These symptoms are not those of eczema. In 
ringworm of the scalp the hairs loosened in their follicles are usually 
either brittle or are actually broken at a short distance from the scalp; 
the scales are fine, dirty white, and not torn from the surface by the 
finger-nails. In eczema the hairs are unaffected, and their extraction 
from the follicles is productive of pain. 

In ringworm of the body the patches are distinctly circular, are 
more scaly or papular at periphery than centre, and, moreover, yield 
with exceeding promptness to the action of a parasiticide. Occurring 
about the thighs and ano-genital region, the disease may be complicated 
by eczema, but the characteristic “festooning ” of the advancing border 
of the patch downward along the thigh, or upward over the pubes, 
will suggest a microscopical examination of the scales scraped from the 
surface. 

Tinea Favosa. The cup shaped, friable, yellowish crusts of favus 
on the scalp might be mistaken for the crusts of eczema of the same 
part; but here the exudation is slight, and there is little scratching, as 
in eczema, hence no history of discharge. The odor, moreover, is 
characteristic. In case of uncertainty the microscope would indicate 
the parasitic nature of the disorder. 

Tinea Versicolor. In this disease, also, the microscope will 
reveal, beneath the epidermal plates, the spores and filaments of the 
fungus which produces the ailment. From eczema the disease is easily 
distinguished by the absence of infiltration and of any history of in¬ 
flammation; by the very slight subjective sensation it produces; by its 
peculiar fawn to chocolate-colored, slightly yellowish patches, with 
superficial furfuraceous desquamation, limited often to the anterior sur¬ 
face of the trunk, and readily removed by the action of a parasiticide. 

Urticaria. In papular forms of this disease there may be a resem¬ 
blance to eczema. This resemblance is more marked in children, as 
here the two diseases may be intermingled. Characteristic wheals 
often occur by the side of eczematous patches, but, as a rule, urti¬ 
carial lesions are less grouped, more generally disseminated, more 
evanescent, and much less scratched. 

Treatment. It is proposed to describe here the treatment of eczema 
in general, reserving the consideration of the treatment of the forms 
occurring in particular localities of the body, to the pages which follow', 
and which are allotted especially to such local manifestations of the 
disease. 

In acute eczema, as well as in many of the chronic forms of the 
disease, the first and most important requisite is that which is the sim¬ 
plest, and, perhaps, for that reason, most commonly overlooked. This 
requisite is the exclusion of all sources of irritation. 


INF LAMM A TIONS. 


315 


This exclusion completely secured, a large number of cases of the 
disease will proceed to prompt recovery without other treatment. 
Failing to secure resolution, acute become chronic phases of the dis¬ 
ease; or there is a history of exacerbation, recurrence, or development 
of the disorder in new and perhaps distinct portions of the body, from 
reflex irritation or augmentation of the sensitiveness of the skin to 
other sources of mischief. 

The exclusion of all sources of irritation necessitates, first, the with¬ 
holding of all harmful internal medicaments. The number of patients 
presenting themselves for treatment of this disease, both in dispensaries 
and hospitals, and in private practice, who have aggravated their 
eczema by medicaments they have swallowed, is incredibly large. 

Men and women, infants and adults, those who have been under the 
charge of physicians, and those who have purchased their drugs of an 
apothecary at the suggestion of the latter or of their friends, exhibit 
patches of acute or of chronic eczema, intensely aggravated by the 
injudicious use of arsenic, iodid of potassium, bromid of potassium, 
Donovan’s solution, and other harmful preparations contained in the 
various “ blood-purifying ” remedies sold in the shops. The practi¬ 
tioner whose patient comes to him after making trial of any such 
remedies, is strongly urged to set aside the operation of such mis¬ 
chievous agents, and to watch the eruption carefully, while their effect 
is vanishing. The result is often marvellous. 

The exclusion of all sources of irritation necessitates, secondly, the 
avoidance of all injurious external contacts. Only gross ignorance or 
carelessness will overlook the fact that the inflamed skin, like the 
inflamed bone or the inflamed bladder, calls imperatively for rest. 
The prevalent idea, however, is that the patient with an inflamed joint 
retires to his couch or bed, while the patient with an eczema, if his 
disease be not so formidable as to necessitate temporary withdrawal 
from the pursuits of business or of pleasure, belongs always to the 
peripatetic class. He consults a physician, swallows some medicine, 
anoints his eczematous skin with a salve, and returns to the vocation 
where his complaint was begotten, just as the man with gonorrhea will 
occasionally solace himself by embracing the source of his affliction. 
The baker goes to his baking; the wearied seamstress still pushes her 
needle through the dyed fabrics which first injured her hand; the man 
with an eczema.of the thigh walks the street with his trowser-leg 
rubbing the affected surface; the nursing mother, with an eczema of 
the infra-mammary region, still suffers the milk, chemically altered in 
the heat of the summer, to flow over the tender surface of the breast; 
or, in the case of her infant affected with eczema, stuffs the folds of a 
coarse diaper, half laundered or vet covered with the dejection from 
the bowels, between its thighs and over the anal region. 

Next is involved the exclusion of all topical irritants (in the hands 
of either physician or patient) designed to relieve the disorder, but 
having a precisely opposite effect. The number and variety of these 
articles are far from being commonly appreciated; some are useful in 
advanced stages of the disorder, and harmful in its earlier periods. 
These articles, which are generally ordered by persons with a limited 


316 


DISEASES OF THE SKIN. 


experience in diseases of the skin, represent a long list of stimulating 
and astringent ointments. Some are employed in sheer ignorance of 
their effects, as, for example, crude petroleum, strong acids and alka¬ 
lies, nitrate of silver, turpentine, and concentrated solutions of corrosive 
sublimate, intended to “ burn out” the disease. 

Lastly, the exclusion of all sources of irritation necessitates saving 
the involved surface from the excoriations and other traumatisms pro¬ 
duced by scratching, rubbing, and excessive washing of the eczematous 
skin. In the case of adults some restraint is here needed ; in the case 
of infants this restraint may need to be enforced. This exclusion of 
all sources of irritation to the skin is essential to the proper treatment 
of every case of eczema. 

The methods of treatment about to be described in detail are to be 
regarded as entirely auxiliary to the measures and precautions suggested 
above. If these precautions could perfectly be secured in every case, 
no other treatment would be required. If the patient protest that he 
must continue his vocation—the hands of the sugar-baker returning 
to their accustomed manipulations, the feet of the busy pedestrian to 
the friction incident to his daily locomotion—then let both physician 
and patient distinctly understand the facts of the case. The physician 
advises the speediest method of relief, and the patient elects a slower 
and more uncertain course; in doing this the latter should be made to 
understand that the responsibility is, to that extent, to be borne by 
himself. What competent surgeon consents to be responsible for that 
fracture in which the extremities of the bone are daily subjected to 
movement on the part of the patient! 

The great importance of restand freedom from irritation of all sorts 
in eczema is well illustrated by two classes of cases. There is, first, 
the newborn infant whose sensitive skin responds early to its first 
harsh acquaintance with the outer world, by an explosion of eczema. 
But it is a fact of singular importance that no child is born into the 
world eczematous. If the nervous system were responsible for eczema, 
such a result might occur, for that system is not only capable in intra¬ 
uterine life of producing club-foot and other deformities, but also of 
influencing skin disorders. In the case of pigmentary moles visible at 
birth the lesions are often distributed exactly in the situation of herpes 
zoster of the trunk, along the lines of intercostal nerves. If the blood 
were responsible for eczema, the foetus surely might display its lesions, 
as it does those of syphilis. Animal poisons, as those of variola and 
scarlatina, do not spare the unborn child, nor is it exempt from certain 
diseases of the integument that are generally regarded as due solely to 
tissue-changes, since newborn infants are occasionally seen affected 
with ichthyosis or sclerema neonatorum. 

Why is the tender skin of the foetus exempt from every form of 
eczema, and the tender skin of the infant accessible to each by such 
various approaches ? Will it be responded that the child has begun 
to respire and digest for itself; that it has become suddenly strumous, 
dartrous, rheumic, arthritic, gouty, or herpetic; that its standard of 
health is impaired; that it is suffering from assimilative, nutritive, or 
nervous debility, or from any one of the other numberless perturba- 


INF LAMM A TIONS. 


317 


tions to which eczema has been ascribed? For him who can divest 
himself of all prejudice, there can be but a single answer to the ques¬ 
tion. The difference between the child unborn and the child born is, 
as regards eczema, a difference solely of skin-protection and skin- 
exposure. The former enjoys what White has aptly termed a u pro¬ 
longed, placid, subaqueous life.” Anointed with unguent and immersed 
in its water-bath of grateful temperature, its skin cannot be fretted to 
produce an eczema. The child, abruptly and often rudely brought 
into contact with the outer world may speedily exhibit the most formid¬ 
able symptoms of the disease. 

The second class of cases referred to exhibits the reverse of this 
picture, and the subjects of the disease are best observed in hospital 
practice. Attacked with such severe symptoms of the disease as to 
justify admission to these charities, eczematous patients, usually im¬ 
poverished in their resources and often injured by exposure during 
severe bodily toil, rarely fail to improve greatly during the course of 
a few days, when no treatment of an active sort has been adopted. 
In the larger number of cases, while waiting to study the evolution of 
the disease, one is limited to the observation of its involution. The 
mere rest in bed in a recumbent position, with a proper regulation of 
the diet and the exclusion of all sources of irritation, has here been 
sufficient to secure relief. 

If any apology be needed for the space devoted to this part of an 
exceedingly interesting subject, it must be based upon the great fre¬ 
quency of the disease, the wide diffusion of erroneous doctrines respect¬ 
ing its nature and the method of its management, and the mischief 
resulting from the too common aggravation of the malady iu its earliest 
manifestations. 

The dietary allowed the eczematous patient should be limited to the 
most dige-tible articles of food, and should exclude those known to be 
capable of exciting cutaneous irritation, a list of which is given in the 
chapter on Urticaria. A moderate use of fresh meats at but one meal 
of the day and cooked vegetables and fruits may be permitted; but 
starchy articles in excess, hot breads and cakes, pastry, confectionery, 
cheese, pickles and pickled meats, cucumbers, cabbage both raw and 
cooked, parsnips, turnips, beans, oatmeal, cracked wheat, pease, celery, 
shell-fish, salted fish and meats, pork, and veal should be avoided. 
Milk, when not the source of constipation, may be drunk, but not 
during the meal-hour. Coffee, tea, and cocoa are in the doubtful list, 
as they are positively injurious to some patients, and apparently with¬ 
out effect in others. Tobacco should always be forbidden to male 
patients suffering from anything like a serious eczematous attack. 
Alcohol in every form is contraindicated save in conditions of 
debility or its previous habitual use in moderation by persons of 
advanced years. In gouty cases the dietary should be of the strictest 
appropriate to that condition, and in diabetic eczema the regimen 
proper in glycosuria is observed with great benefit in most cases. 

Internal Treatment. In the management of acute eczema, cooling 
draughts are useful; and in all cases occurring in patients who arc 
plethoric, who are constipated, or who suffer from other symptoms of 


318 


DISEASES OF THE SKIN. 


imperfect excretion, aperients and cathartics are needed. Often a brisk 
mercurial purgative in the form of blue-mass or the compound cathartic 
pill may be ordered at the outset. The rhubarb-and-soda mixture 
answers well in some cases. Podophyllin, irisin, and eupatorium, or 
the familiar combination : nux vomica, aloes, and belladonna, may be 
substituted for these articles. The saline cathartics, whether employed 
in medicinal formulae or in natural mineral waters, such as the 
Hathorn, Carlsbad, Hunyadi Janos, or Friedrichshall, are exceedingly 
useful in the management of most cases. The following is a valuable 
combination often advised for cases where both iron and the sulphate 
of magnesium are indicated: 


-Magnes. sulphat., 

3u; 

64 

Acid, sulphur, dil , 

fsij; 

8 

Ferri sulph., 

3ss; 

66 

Sodii chlorid , 

3j; 

4 

Cardamom, tinct. comp., 

f 3j; 

4 

Aq. dest , 

ad Oss; 

256 


Filtra. Sig.—A tablespoonful before breakfast in a tumblerful of cool or of hot 
water. 

An excellent remedy for some cases is from 15 to 20 drops of a fluid 
containing two parts of the fluid extract of cascara sagrada to one part 
each of glycerin and tincture of aloes, the dose to be taken before 
breakfast in a small glassful of water. 

In some cases of renal derangement the alkaline diuretics are indi¬ 
cated, such as potassium acetate, carbonate, or citrate, administered 
with nitre, squills, caffein, or beuzoate of lithium in from 3 to 5 
grain (0.26-0.33) doses before meals (Piffard); and, in gouty cases, 
colchicum, Vichy water, etc. In patients suffering from acid dyspep¬ 
sia liquor potassse, sodium bicarbonate, or ammonium carbonate may 
be required. 

Aloes and iron, or aloes and ergot, are often indicated in special cases. 
The late Dr. Tilbury Fox employed in cases where diuretics and alka¬ 
lies were both indicated, the following formula: 


-Magnes. sulphat., 

^ss; 

16 

Magnes carbonat., 

3j; 

4 

Colchici tinct., 

f ^ss; 

2 

Menth. pip. ol., 

m ij; 

2 

Aq. dest., 

f 3vj ; 

192J 


Sig—Two tablespoonfuls in a wineglassful of water every three or four hours. 

Cod-liver oil is indicated in all cases of struma and tuberculosis; 
phosphate of lime in bronchitis; steel in anemia and chlorosis. 

In fleshy children affected with eczema capitis calomel internally is 
a valuable remedy, from | grain to 2 grains (0.06-0.133) of calo¬ 
mel, with 2 to 3 (0.13-0.26) of rhubarb, rubbed up with 5 of calcined 
magnesia (0.33), may be given once in a day to an infant; or of a 
grain (0.003) of calomel, rubbed up with sugar of milk, may be given 
three times daily, for ten or twelve days. Vau Harlingen advises 
small doses of the unspiced syrup of rhubarb, with or without magne¬ 
sia, for the constipation of infants, or fronfll to 3 drachms (4.-12.) 
each of powdered rhubarb and bicarbonate of sodium in 4 ounces 
(128.) of peppermint water, of which a teaspoonful may be admin is- 



INF LAMM A TIONS. 


319 


tered two or three times daily. Quinin, strychnin, syrup of the iodid 
of iron, and wine of iron may also be used with advantage when 
indicated in these little patients. 

Beside those numerated above may be named the following articles, 
which, after internal administration, have been reported as efficient 
in the hands of various authorities: Calx sulphurata and Viola tricolor 
(Piffard); hyposulphite of sodium, ichthyol, chrysarobin, tar (for 
adults, 2 drops of purified pix liquida mixed with one-eighth part of 
rectified spirit, gradually increased—Anderson); carbolic acid, anti- 
monial wine in 5 minim doses, sulphur, turpentine, and Hydrocotyle 
Asiatica. 

If the remarks which have preceded are justified by the clinical and 
pathological history of eczema, it follows that there is no constitutional 
treatment of the disease, save that which excludes all sources of irri¬ 
tation. Once fully persuaded of this important truth, the physician 
should be capable of managing the complaint without mental bias in 
the direction of futile experimentation with drugs. 

The treatment of the patient, however, may in one sense be regarded 
as the treatment of his disease, though a very large number of eczema¬ 
tous patients are, except as regards the skin, in conditions of health. 
Constitutional treatment, to meet any general conditions of ill-health, 
should be, in short, such as is made familiar to the physician in his 
experience as a general practitioner of medicine. 

Mention has been made of but few of the disorders in the long list 
which may coexist with eczema. Some male patients with a gleet 
have an eczema of the thigh, kept up by the discharged secretion, 
which calls for treatment calculated in a very indirect manner to 
relieve also the cutaneous disorder; the same may be said of an otitis 
externa with a purulent discharge, and of other local aud constitu¬ 
tional ailments which the skilled physician should be competent to 
recognize and to treat. Be it clearly understood the while, that all 
such treatment will not relieve an eczema. It simply places the patient 
in the most favorable condition for getting rid of local trouble. If 
one has had the opportunity of observing a large number of eczema¬ 
tous patients of every social class treated by internal medication of the 
character approved by those who still cling to a belief in the constitu¬ 
tional nature of the disease, he will see that the statements here made 
are based upon a conscientious study of this experience, and of the 
results of personal experiment in the same direction. He who desires 
to build solidly will not lay his corner-stone upon the shifting sands, 
where so many have been disappointed before him. 

Bearing in mind the fact that an eczema will occasionally vanish even 
under the worst mismanagement, the value of arsenic administered inter¬ 
nally for its relief may be duly estimated. Arsenic is an uncertain 
remedy in all cutaneous diseases; it is equally as uncertain in eczema, 
and has unquestionably aggravated as many cases as it has relieved. Its 
value in chronic and persistent forms of the disease is attested by men of 
distinguished reputation, and upon such authority it may be conceded 
a position among the internal remedies of possible value for the malady. 


320 


DISEASES OF THE SKIN. 


It is indeed not so remarkable that a few patients annually recover 
under its administration as that more do not attain the same fortu¬ 
nate end; for in chronic scaling diseases of the skin it is the favorite 
premier ressort with physicians of every grade of professional profi¬ 
ciency; and, having in view the large percentage of eczematous cases 
with which they are confronted, it is a curiously suggestive fact that 
the position of arsenic in eczema is yet open to discussioc. If arsenic, 
which certainly does possess an influence over the skin, cannot to-day 
be demonstrated to have therapeutic value in the large proportion of 
all cases of eczema, what can be said for the host of other drugs, too 
commonly employed for a similar purpose, that are inferior to arsenic 
in their cutaneous effects ? Sunlight, fresh air, suitable clothing, and 
due regime as to pleasure and business; must be, for many patients, 
controlled by the physician; they do not cure eczema. They do much 
to aid in its management; they may do more, if neglected, to furnish 
sources of its aggravation. Crocker advocates counter-irritation over 
the spine—over the nape of the neck for eczemas of the upper segment 
of the body; over the dorso lumbar vertebrae for the lower parts. 
Jackson has used the ice-bag with advantage in the same way. 
Counter-irritation of the corresponding part of the lateral half of the 
body for the relief of an eczematous patch of long standing limited 
strictly to the other side may also be employed in rare cases. 

External Treatment. The most soothing applications which can be 
made to the skin affected with acute eczema are, in various proportions 
and combinations, water, oil, dusting-powders, and occasionally oint¬ 
ments. These substances will separately be considered, but two im¬ 
portant circumstances must be remembered in their employment—first, 
that an article which will be grateful to the skin of one patient may 
prove irritating to another, the two being to all appearance similarly 
affected; second, that where the surface is broken, from rupture of 
vesicles, excoriations, abrasions, or fissures, an applied fluid should be 
of greater specific gravity than the serum exuded, since otherwise 
endosmosis and exosmosis will occur, and the surface in consequence 
will become more tumid and painful. 

Olive-oil or other bland oils may be poured over the surface, be 
applied upon folded pieces of lint, or be used by inunction. Even the 
oils, however, are at times sources of irritation. They are made 
more soothing by combination with an equal part of liquor calcis, 
as in Carron oil, constituted of equal parts of linseed-oil and lime- 
water. For the linseed oil it is frequently advantageous to substitute 
cod-liver oil, palm-oil, oil of sweet almonds, neat’s-foot oil, olive-oil, 
or lard-oil, flavored very slightly with bergamot or with lavender to 
correct the disagreeable odor. In combination with an equal part of 
lime-water, one of these oils may gently be smeared over the surface, 
while a piece of lint saturated with the same preparation is also applied. 
In many cases the value of this dressing is greatly enhanced by sur¬ 
rounding the whole with oiled silk or other impermeable tissue. * 

The dusting-powders, described in the chapters on General Thera¬ 
peutics and the Erythemata, are available in many cases where the 
surface of the skin is or is not broken. These powders may be 


INFLAMMA TIONS. 


321 


lycopodium, magnesium, boric acid, bismuth, talc, oxid of zinc, or 
camphor when an antipruritic effect is desired, in combination with 
finely powdered starch. The Anderson powder, the formula for which 
has already been given, is a useful combination of camphor, starch, 
and zinc. In the preparation of dusting-powders it is of prime im¬ 
portance that they be made perfectly impalpable by sifting them care¬ 
fully through silk bolting-cloth, as they are sources of irritation when 
they contain grain-like particles of untriturated material. The finely 
bolted “ Oswego gloss-starch,’ 7 “ corn-starch farina,” and rice-flour 
(sold by grocers) may be applied either singly or combined with the 
other articles named, which are generally accessible. It will often be 
of advantage, where exercise in the day is not prohibited, to employ 
during the night one of the oily preparations, which can be removed 
in the morning by a weak alkaline bath containing borax or sodic 
bicarbonate, while the patient employs a dusting-powder in the day¬ 
time. The powder can be dusted freely over the affected surface, as 
also over the soft lint in contact with the eczematous skin; the stocking, 
glove, or suspensory bag being also well protected on its inner face 
by the powder. 

Water is of value in many cases when properly applied. Excessive 
washing of the eczematous surface is not only disagreeable to the 
patient, but is also irritating to the inflamed skin. Hot water applied 
either as a lotion, a bath, a fomentation, or by sponging, is frequently 
grateful and alleviates the itching. If employed at all, its use should 
immediately be followed, as soon as the part is carefully dried, by the 
other medicament selected for topical application, such as an oily or 
fatty substance, or a dusting-powder. 

Cold water is of service only when it can continuously be applied, 
as its intermittent employment is followed by a vivid reaction in the 
skin-capillaries, whereby the itching is greatly increased. Thus are 
explained many of the nocturnal exacerbations of the disease, notably 
those occurring soon after the patient retires to his or her bed. Cold 
bathing of the part before retiring has been followed by a temporary 
calmative effect, the blood being driven from the capillaries by the 
contraction of the tissues; the return of the circulating fluid in excess 
has then been aided by the warmth retained by the bed and the bed¬ 
clothing. The continuous application of cool or cold water requires a 
constant supply of the fluid from a reservoir of fixed temperature, and 
the exposure to the air of the part to which the dressing is applied. 
Thus evaporation is not checked, and what is intended to be a con¬ 
tinuous cold dressing is not transformed into a hot fomentation. 

Such fomentations, however, are frequently grateful to the patient’s 
skin, and at times fulfil a good purpose. They are applied by dipping 
pieces of soft cloth into hot water, applying them neatly over the 
affected surface, and covering them with oiled silk, rubber cloth, or 
the “ protective material” employed in antiseptic surgical dressings. 
Poultices of flaxseed, of elm-bark, or of other bland material operate 
in a similar manner, but they are chiefly useful in softening crusts or 
other morbid concretions upon the skin-surface. When too continu¬ 
ously or too frequently employed poultices are productive of harm in 

21 


322 


DISEASES OF THE SKIN. 


their macerating and relaxing effect upon the skin, whereby its natural 
tonicity and instinct of self-repair (if such a term be permitted) are to 
a degree obtunded. Hence they are but little used in eczema. The 
combined employment of water and fatty substances is an exceedingly 
valuable method of soothing the eczematous skin, but, with the means 
accessible in the private practice of many physicians, this combination 
can rarely be secured. The complete immersion of an oiled skin 
certainly approximates most closely the sebaceous envelope and warm- 
water bath of fetal life. The eczematous skin is first anointed gently with 
a bland unguent, such as mutton-tallow, suet, cold cream, or vaselin, 
and is then immersed in a bath of water kept continuously at the tem¬ 
perature of the blood. In the case of the lower extremities this immer¬ 
sion is accomplished without great difficulty. Less perfect than this 
immersion is the anointing of the surface and the subsequent applica¬ 
tion of a warm fomentation, by strips of soft lint dipped in water, 
superimposed with neatness, and subsequently covered with the protec¬ 
tive gauze. Imbibition of fluids by the skin is prevented by its careful 
anointing; when immersed in the water the pressure is both uniform 
and gentle. 

Medicated water in baths and lotions plays an important part in the 
treatment of acute eczema. Liquor calcis with calomel, J drachm 
to 1 drachm (2.-4.), and pure glycerin or mucilage, j- ounce (16.) to 
the pint (512.); lead-and-opium wash; glycerin 1 drachm (4.) to 
liquor plumbi subacetatis 4 ounces (128.); carbolic acid 1 drachm (4.), 
and glycerin 2 drachms (8.) to 1 pint (512.) of camphor or of lime- 
water; a decoction of opium, made by boiling from 5 to 10 grains 
(0.33-0.66) of powdered opium in a pint (512.) of water, then strained 
and rendered demulcent with mucilage; sulphate of zinc from 10 to 30 
grains (0.66-2.) to the pint; dilute hydrocyanic acid 2 drachms (8.) to 
the pint of water; these and similar lotions, the ingredients of which 
are changed to suit the indications of each case, often serve to alleviate 
the itching, and in that proportion to diminish the intensity of the 
disease. White, of Boston, after bathing the parts for several minutes 
with lotion nigra, dilute or in full strength, gently smears the affected 
surface with a small quantity of oxid-of-zinc ointment, or in winter, 
4 scruples (5.) of powdered zinc oxid to J ounce (16.) each of cold 
-cream and vaselin. Taylor, of New York, has suggested the following: 

R.—Liq. plumbi subace tat., £ij ; 81 

Opiitinct, §ij; 64 

Camphorae tinct., % j; 32 

Glycerinse, |ij; 64| M. 

To this solution a greater astringent effect can be given by the addi¬ 
tion of subnitrate of bismuth, or oxid of zinc, | ounce (16.) of either 
to the pint (512.) of the lotion. 

Duhring, of Philadelphia, has popularized the use of fluid ex¬ 
tract of Grindelia robusta, in the proportion of one part to four of 
water, as a lotion in eczema. Excellent lotions for soothing effect are 
also made by adding 1 to 2 drachms (4.-8.) of sodium bicarbonate to 
a quart of thin oatmeal gruel or of marshmallow decoction. Many 


INF LAMM A TIONS. 


323 


patients will in this way secure relief which they cannot otherwise 
obtain. 

Other useful lotions contain finely levigated calamin, 1 to 2 ounces 
(32.-64.) to the pint of rose-water, with a small quantity of glycerin, 
and if the itching be severe, in addition drachm (2.) to 1 drachm (4.) 
of dilute hydrocyanic acid; boric acid, 1 to 2 drachms (4.-8.) to the 
pint of an opiated wash. Thymol, one part to one thousand, or borax 
or bicarbonate of sodium in the same proportion, containing beside 
an equal proportion of alcohol, spirits of camphor, or chloric ether, is 
also available. With any of these lotions it is proper to moisten fre¬ 
quently the soft lint upon which they are applied, after ablution of the 
part with hot, pure, or slightly medicated water, for the purpose of 
relieving the itching. 

Poultices made of bread-crumbs or of starch mixed with ice-cold 
lead-water, or fomentations made by wetting cloths with chamomile- 
water, and covering them with gutta-percha or other impermeable 
tissue, are at times exceedingly grateful to the eczematous skin. 

From what has preceded, it will be clear that the chief end in the 
treatment of an acute eczema is the relief of the subjective sensation 
of itching and the exclusion of all irritants, the two being practically 
one. That treatment which is not grateful to the skin of a patient 
thus complaining had better, for the time at least, be abandoned. So 
great is the difference between different patients as to the toleration by 
the skin of various topical remedies, that it is well, as a rule, at the 
time of a first consultation, to order an alternative treatment, the one 
to be immediately substituted for the other, if the necessity arises. 
Especially is this change of treatment necessary in cases where the 
epidermis is wounded, and where the patient can sometimes with com¬ 
fort to himself exchange a dusting-powder for a lead-wash or a weak 
carbolized-oil and lime-water lotion, while his eczema is tormenting 
him in different degrees at different hours of the day. 

The necessity for this relief is so imperious that at times the itching 
overshadows all other symptoms of the disease. He who has never 
studied the case of a man or a woman possessed with a furious impulse 
to relieve an intense eczematous pruritus has not yet completed an 
education in medicine. This fury, for such it really is, has been 
likened to the sexual orgasm, with which it is undoubtedly allied, as 
the two are not rarely coincident when there is severe anal or genital 
itching. The features of the patient are drawn; he is but half-con¬ 
scious of his ejaculations and surroundings; with his nails, or other 
object which he employs, he attacks the too vulnerable skin with an 
incalculable savagery. In these exaggerated paroxysms nothing but 
blood will suffice for his relief. Not until the torn and wounded sur¬ 
face oozes with red drops at every point does he emit the sigh which 
indicates that his desire is satisfied. Men and women forcibly withheld 
from doing themselves this severe damage will at times exhibit the 
muscular spasm, facial expression, and movements of body scarcely 
distinguishable from the symptoms of petit mal in an epileptic seizure. 
This brief oudine of a picture familiar to those who have had expe¬ 
rience in rare and exaggerated cases will serve to enforce the need of 


324 


DISEASES OF THE SKIN. 


the utmost care in selecting a topical remedy in acute eczema, the 
greatest gentleness in its application, and the nicest provision for the 
special needs of each individual patient. 

In proportion as the disease progresses to a subacute or a chronic 
stage, the various topical medicaments employed may be changed in 
character so as to produce an astringent or a stimulating effect upon 
the part. The utmost skill and prudence, however, are needed at this 
juncture; and when uncertain as to the proper course it is well to 
continue the dusting-powder, alkalinized gruel, oleated lotion of lime- 
water, or whatever other article may externally be employed. For it 
is at this time that the disorder is readily awakened to renewed activity, 
a turn of affairs which is especially annoying to the patient, and par¬ 
ticularly so to the practitioner, if there be a suspicion (truth to tell, 
often too well founded) that the aggravation has been due to the treat¬ 
ment. It goes without saying that the routine practice in eczema 
has long been to order an application of benzoated oxid-of-zinc oint¬ 
ment, irrespective of particular features of the malady in any indi¬ 
vidual case. No greater error in this special direction could be 
committed. The acutely inflamed skin will rarely tolerate the most 
perfectly medicated ointment, and as this acuteness subsides such 
tolerance is first to be carefully tested, as, for example, by applying a 
weak ointment to a part only of the affected surface. The term 
“rarely” is, however, here used advisedly. With that singular 
capriciousness which distinguishes the eczematous skin of different 
individuals, zinc ointment occasionally affords very great relief in the 
severest forms of acute vesicular disease. 

In the application of ointments it should be remembered, first, that 
they must be sweet and freshly and carefully prepared; second, that 
they can advantageously be applied by gently rubbing them into the part 
by the tip of the finger, after which soft lint in strips, spread with the 
same material, may neatly be superimposed; third, that an ointment, 
if selected, need not necessarily be applied to every part of the inflamed 
skin, since a little pad or a circlet of lint may be placed only on an 
oozing or a pustular patch; lastly, that the debris of one dressing 
should carefully be removed before another application is made. Strata 
of any ointment, the older next the skin possibly rancid and having 
imprisoned beneath them pus or other products of the disease, are 
a positive source of harm. 

One of the most valuable of the preparations useful at this period 
of the disease is some modification of the Lassar paste, in which two 
parts each of finely powdered talc, or of rice-flour, and zinc oxid are 
well incorporated with four parts of vaselin, and from 1 to 3 per cent, 
of salicylic acid added to the whole. 

The most soothing ointments for use at this stage are benzoated 
oxid-of-zinc salve, which may be reduced with cold cream one-half or 
more for extremely sensitive conditions of the skin; Hebra’s diachylon 
ointment, described later, of which one part may be combined with 
three or four parts of vaselin or of cold cream and from 5 to 10 grains 
(0.33-0.66) of salicylic acid added to each ounce (32.) of the whole; 


INF LAMM A TIONS. 


325 


or oleate of bismuth, prepared according to the formula of McCall 
Anderson given below. 

Appended are a few formulae for ointments useful in this stage of 
the disease: 


R.—Zinci oxid , 

Hydrarg. amrnon. chlorid., 
Camphor, pulv., 

Ungt. aq. ros , 


3ss; 
gr. y.-^ss; 
3ss-|j ; 


2 

33-66 

2-4 

32 M. 


For the oxid of zinc may be substituted sub nitrate or subcarbonate 
of bismuth; or from 2 to 4 grains (0.133-0.266) of red oxid of mer¬ 
cury; or from 4 to 10 grains (0.266-0.666) of mild chlorid; or from 
10 grains to a J drachm (0.66-2.) of ammonium chlorid. Cold cream 
makes an agreeable basis for these ointments, though lard, simple 
cerate, lanolin, vaselin, or equal parts of vaselin and a cerate answer 
a good purpose. The cerates are made sufficiently soft for gentle 
manipulation by adding 1 or 2 (4.) drachms of glycerin to each ounce 
(32.) of ointment, and they may be flavored with lavender, rosemary, 
or bergamot, as may be preferred. 

The oleate of bismuth or of zinc is prepared by rubbing up 1 drachm 
(4.) of the oxid of either metal with 8 (32.) drachms of oleic acid, 
which is then allowed to stand for two hours. It is afterward heated 
in a water-bath, when 10 drachms (40.) of vaselin and 3 (12.) of wax 
are dissolved in it, the whole to be stirred until cold. This ointment 
is especially useful when employed in papular forms of eczema. 

The well-known diachylon ointment of Hebra occupies a foremost 
place in all lists of articles useful at this period of the disease and even 
later. It is prepared as follows: 

To 14 ounces of the best olive-oil are added 2 pounds of water, and 
the whole heated to boiling in a water-bath; 3 ounces and 6 drachms 
of an equally good article of litharge are dusted over the fluid in ebul¬ 
lition, which is constantly stirred throughout to prevent the formation 
of fatty acids. During the cooking, water is occasionally added as 
required. The stirring is to be continued until the ointment is quite 
cold. Duhring has modified this ointment as follows: 

One part of freshly precipitated (from acetate of lead) pure white 
hydro-oxid of lead is rubbed down with two parts of water, and well 
mixed with six parts of the best Lucca olive-oil. The mixture is 
stirred for about two hours over a hot-water bath near the boiling- 
point, and is then cooled with constant stirring until the proper con¬ 
sistence is obtained; while the mass is cooling 1 drachm of the oil of 
lavender is added to each J pound of ointment. This preparation, 
according to Eisner, a Philadelphia chemist, isjsaid to contain oleo- 
stearate of lead. 

When properly prepared this ointment is perfectly homogeneous, is 
of a light yellowish color, and is of the consistency of butter. It has 
been modified by Piffard, and after him by Kaposi, in combining equal 
parts of lead-plaster and vaselin. It is commonly flavored with the 
oil of lavender. It is technically known as the “ unguentum diachyli 
albi ” of Hebra. It may be imitated fairly well by melting together 



326 


DISEASES OF THE SKIN. 


two or three parts of olive-oil and four of diachylon plaster, and 
stirring until cool. 

This valuable ointment, though useful often in full strength and 
even to the exclusion of all other pomades, is yet with such others 
often combined with manifest advantage. Thus, 1 or 2 drachms (4.-8.) 
of it may be added to the ounce (32.) of lard, cold cream, or cerate, 
with or without the addition of another drachm or two (4.-8.) of 
oxid-of-zinc ointment, or even of one of the tarry preparations to be 
mentioned later. 

For the management of acute eczema many to-day rely upon the 
salve-muslins, glycerolates, pastes, etc., which are fully described in 
the chapter on General Therapeutics. Unna’s paste is prepared by 
mixing 1 ounce (32.) of zinc oxid with 2 ounces (64.) each of glycerin 
and mucilage. To this mixture may be added 1 per cent, of carbolic 
acid or salicylic acid, the whole to be applied with a brush. 

Veiel recommends as a mull for the face and genitals: 


R .—Emplast. plumb, simpl., 
Sebi benzoinati, 

Adip. benzoinat, 


aa 3 ijss; 
3 ss; 


To make benzoated sebum: 


R.—Seb. taurin., 3 ijss; 

Benzoes subtil, pulv., grs. xv; 

Digere in balneo vapor, per horas duas et cola. 

To make benzoated lard : 


10 

2 


M. 


lOj 

l| M. 


R.—Adipis, 3 ijss; 101 

Benzoes subtil, pulv., grs. xv; l| M. 

Digere in balneo vapor, et cola. 


With these unguents may be named glycerole of starch, cucumber 
ointment, emulsion of sweet almonds, decoction of Irish moss, and 
Hardy’s formula—two parts of oxid of zinc, eight of glycerin, thirty 
of cold-cream salve, and 15 drops of tincture of benzoin. 

In chronic eczema it is necessary at first to remove from the surface 
all dried products of the inflammatory process that usually remain upon 
the surface, such as crusts, scales, and masses of effete epidermis. For 
this purpose oil is to be freely used, and care should be taken that it 
is rubbed gently into every part of the affected patch. A species of 
oil-poultice may also be applied by saturating pieces of flannel or layers 
of antiseptic cotton with either olive or cod-liver oil, and covering 
these pieces with protective silk-gauze and a light bandage. As soon 
as the inflammatory products are softened they are removed by wash¬ 
ing with soap and water, using for this purpose either the ordinary 
toilet-soap, or, where the skin will permit, the spirit of green soap, 
described in the chapter on General Therapeutics. 

The Sarg glycerin-soap is an admirable substitute for these articles 
when the skin is tender, and where an elegant toilet-preparation can 
be ordered. The crusts and scales once removed, subsequent topical 
applications may be made as required in each case. 

The acuteness of the disease having fairly subsided, not only as 



INFLAMMA TIONS. 


327 


regards the question of time, but more especially as concerns the ques¬ 
tion of what the skin will tolerate, the tarry and allied preparations 
become for the first time worthy of consideration. Valuable, indeed, 
when such toleration has become experimentally established, they are 
sources of positive injury when the acuteness of the inflammatory 
process has not completely subsided. 

The articles of this class most commonly employed are pix liquida 
(pine tar), oleum rusci (oil of white birch), oleum cadinum (oil of 
cade), and Terebinthina canadensis (the balsam of fir). Oil of cade, 
as found in most of the shops, is inferior to oleum rusci. The tars 
are best applied in the form of ointments, but are occasionally painted 
over the affected surface in a liquid state with a camel’s-hair brush. 
From J to 2 drachms (2.-8.) of tar, in combination with a suitable 
quantity of subcarbonate of potassium, are sufficient to add to 1 ounce 
(32.) of ointment, the proportions suggested being varied to suit the 
requirements of each case. In attempting to meet such require¬ 
ments it may occasionally be found useful to combine with these 
ointments oxid of zinc, mercurial compouuds, or diachylon ointment 
of Hebra. 

The following formulae are illustrations merely of the manner of 
compounding these articles: 


&.— 01 . rusci (vel cadini), gss- 3 jss ; 

Potass, subcarbonat., 9j _ 3 ss > 

Unguent, aq. ros., ; 

Ft. ungt. 


1-6 

.66-2 

32 


M. 


For the potassic subcarbonate J to 1 drachm (2.-4.) of zinc oxid 
may be substituted, or from 2 to 4 grains (0.133-0.266) of red oxid 
of mercury, or yet J scruple (0.666) of mild chlorid. The vehicle, 
also, of such ointments may be vaselin, lanolin, simple cerate, or J ounce 
(16.) of either in combination with an equal quantity of diachylon oint¬ 
ment. 

Of fluid preparations may be mentioned alcoholic solutions of 
tar, J ounce (16.) of the latter to the pint (512.) of alcohol; and in 
cases where the detersive action of soap is also needed sapo viridis 
may be added as follows : 


11.—Picis liquids, 

f 5j-ij; 

32-64 

Sapon. virid., 

f^jss-iij : 

48-96 

Glycerin , 

m ; 

32 

Spts vin. rectif., 

f 3 viij; 

256 

01 . rosmarin., 

fgss; 

2 

Sig.—To be rubbed gently into the skin with 

a flannel rag. 


Bulkley, of New York, devised an alkaline solution of tar and 
caustic potassa, which is especially serviceable, as it is miscible with 
water in all proportions, and which is constituted as follows : 


H. —Picis liquidse, 


641 


Potassse causticse, 

3j; 

32 


Aq. destillat., 


160! 

M. 


Dissolve the potash in the water, and add slowly to the tar in a mortar with 
friction. 

Sig.—“ Liquor picis alkalinus ” To be used diluted as a lotion. 




328 


DISEASES OF THE SKIN. 


Of this solution 1 drachm (4.) or more may be added to a pint (512.) 
of water. As an ointment, the same quantity of the solution may be 
added to the ounce (32.) of cold cream, lanolin, or vaselin. It should 
be remembered, however, that the caustic alkali renders this prepara¬ 
tion exceedingly irritating to a sensitive skin, and it should be employed 
with caution upon any untested surface. 

The formula recommended by Spender, and described in the chapter 
on General Therapeutics, is a useful means of testing the efficacy of 
tar upon an eczematous surface. When fluid or semifluid compounds 
of tar are needed upon the scalp 1 drachm (4.) of the article selected 
may be rubbed up with an equal quantity of glycerin and added to 6 
ounces of cologne-water (192.). 

Hebra disclaimed any special value for sulphur in eczemas uncom¬ 
plicated by the acarus scabiei, but in Wilkinson’s and other ointments 
it has certainly served a good purpose. The following formula sup¬ 
plies an ointment rather less severe, that has practical efficacy in chronic 
eczema: 

R.—Picis liquid, (vel ol. rusci), E iv; 

Adipis, Ej 5 

01. olivae, E ss I 

Misce et adde, 

Terebinth. Canadens., \ aa z:. 

Sulphur, flor., J 5J ’ 

Sig.—To be applied three times daily with a soft brush 

To this formula may be added green soap, if a stronger effect is 
desired. 

Olive oil or cod-liver oil may be rubbed into the eczematous skin, 
after its combination with equal parts of one of the tarry preparations; 
carbolic acid in lotion, or in ointment with balsam of Peru, though 
less effective, answers well in many cases. 

Ichthyol, in ointments of the strength of 10 per cent, and less, is 
useful in localized patches of the disease, especially of the papular 
and scaling varieties. Ammonium sulpho-ichthyol is preferable to 
the natrium compound. Its influence upon the skin seems to resemble 
both that of the tars and of chrysarobin, and cannot be regarded as 
greatly, if at all, superior to these agents. 

Whichever article be selected, it should be thoroughly rubbed into 
the affected surface several times in the day, after a small portion of 
the skin has been attacked to test its susceptibility. Should the redness, 
itching, secretion, and infiltration be aggravated by such application, 
it will be needful, for a time at least, to exchange the local treatment 
for one less stimulating. Should, however, the tarry or other similar 
application be well borne, it should be reapplied until it is no longer 
washed away by the ooze from the skin. Sometimes it is well to permit 
the former to accumulate until it is naturally shed from the surface by 
exfoliation, a course which will be indicated by the absence of all 
local distress. The new epidermis, which forms beneath such coating, 
should be for a time protected by a dusting-powder. Occasioning no 
further subjective sensation, the new epidermis speedily loses its red¬ 
ness and assumes a normal appearance. 


128 

32 

16 



INFLAMMA TIONS. 


329 


In other cases, indicated by local distress and exaggerated secre¬ 
tion, it will be found useful completely to remove the tarry appli¬ 
cation. After saturating it for a few hours with oil, the affected 
surface may be cleansed with a weak alkaline lotion, and the tar com¬ 
pound then be reapplied to the oozing skin with flannel or with a 
camel’s-hair brush, according as recourse is had to an ointment or to 
a solution. 

Hebra formerly employed in chronic eczema of obstinate kinds a 
remedy which he claimed to be his ultimum refugium , and which u cures 
every case without exception,” namely, concentrated liquor potassse. 
There are grave objections, however, to its use; it produces severe pain, 
and in inexperienced hands it is dangerous. As a consequence, this dis¬ 
tinguished dermatologist subsequently adopted two methods which he 
regarded as partial substitutes for it. The first was inunction of 
the body thoroughly and firmly with green soap, which was not removed 
by washing, but was left in contact with the skin for several days, 
while the patient was wrapped in blankets. The secoud was his well- 
known method of treating more circumscribed patches of chronic 
eczema with soap-washing and ointment, the process being described 
below in nearly his own language. 

A piece of green soap, as big as a walnut, is spread upon a flannel 
rag, and rubbed into the eczematous part for several minutes, pressing 
firmly the while, and from time to time dipping it into water in order 
to produce a better lather. The part is then washed free from suds 
with water, carefully dried, and the oil or ointment selected for topical 
use immediately applied on strips of muslin. These are neatly ban¬ 
daged to the part. The soap must be rubbed in at least twice every 
day, so long as any excoriated points appear after its application. Soap 
rubbed into the healthy skin will not be followed by such effects, the 
part feeling clean, smooth, and comfortable after it has been washed 
off in water. The contrast this offers to the eczematous parts is very 
striking, the latter presenting numerous intensely red, raw, and moist 
spots. These are all caused by the action of the soap in softening and 
destroying the layer of cuticle which was before uudermined bv the 
eczematous fluid so as to form coverings for vesicles. Each, therefore, 
represents the floor of a vesicle, the roof being removed. The appear¬ 
ance of these red, shining, moist points after the first inunction suggests 
to the inexperienced eye that the malady has been aggravated; but they 
become fewer in number after each application, and finally entirely 
disappear, the eczematous surface being then no more affected by the 
soft soap than is the surrounding healthy skin. 

For the production of marked effect upon different patches of the 
eczematous skin—those, for example, upon the palms and soles char¬ 
acterized by callosities, thickening, or even verrucous growths—a 10 
per cent, salicylic-acid salve can be used after the shampooing, or Unna’s 
salicylated gutta-percha plaster-mull. 

Energetic effects are also obtained by the use of naphtol, chrysa- 
robin, and pyrogallol, in the strength of from one part to ten, to one 
part to thirty of salve. It is well to begin with a strength not exceed¬ 
ing 1 to 2 per cent., and gradually to increase. 


330 


DISEASES OF THE SKIN. 


Frazer 1 speaks highly of the application of iodoform to eczematous 
patches. It is employed in the form of an ointment, containing from 
10 to 30 grains (0.66-2.) of powdered iodoform to the ounce (32.) of 
cerate. 

Almost every one of the circumscribed patches of chronic eczema are 
greatly benefited by daily painting with saturated solution of pyok- 
tanin blue, the value of which depends almost wholly upon its action as 
an antiseptic agent. It is quite unproductive of pain in the enormous 
majority of all cases in which it is employed, and, as it forms a thin 
scale over the surface to which it is applied, probably serves a good 
purpose for the time being by the exclusion of air. 

It has been painted thickly over the face, the anus, the trunk, and 
the extremities in scores of cases, and one rarely is disappointed in 
the results obtained. When the effect is markedly beneficial it leaves 
little to be desired in the way of local treatment. The chief objection 
to its employment lies in the staining it produces not only of the skin, 
but also of all articles brought into contact with it. 

Another valuable agent in the local treatment of these varieties of 
eczema is formalin, a solution representing 40 per cent, of formal- 
dehyd. It is rarely tolerated by the skin in a strength greater than 
from 1 to 2 per cent., but when the strength is properly adjusted to 
the sensitiveness of the integument it completely meets a distinct indi¬ 
cation for its use. 

Other stimulating articles have been found useful in the treatment 
of eczema. Among these may be named cantharides, employed as a 
blister, the nitrate of silver in crayon or in solution, from 3 to 10 
grains to the ounce, and iodin in combination with carbolic acid. The 
following formula should furnish a clear vinous-red fluid, which may 
be applied pure or in dilution: 

&.—Iodin. tinct., gss; 

Acid, carbolic, (cryst ), gj ; 

Glycerin. ,1 .. „.. 

Alcoholis, J aa 3 y » 

Aq. destillat., ad f; 

Sig.—Iodized solution of carbolic acid. 

In cases where there is considerable pruritus, especially in obstinate 
patches of papular eczema, the iodized phenol of Bellamy may be 
substituted for the above. The formula is: 


2 

4 

8 

32 M. 


B.—Iodinii cryst., \ . A 

Acid, carbol., j > 4 | 

Combine with gentle heat and add an equal part of glycerin. 

Sig.—Iodized phenol; to be applied twice daily with a glass rod. 


Balmanno Squire, of London, suggested a substitute for diachylon 
ointment, in glycerole of the subacetate of lead. It is certainly a 
valuable preparation in many cases, but not superior to the other 
ointment named. The “ stock ” is prepared as follows: Take five 
parts of acetate of lead, three and one-half parts of litharge, and 
twenty parts of glycerin; heat for half an hour in a boiling glycerin- 


1 British Medical Journal, July 16,1881, p. 80. 


I NFL A MM A TIONS. 


331 


bath, constantly stirring, and filter in a gas-oven or other kind of 
heated apartment. From J drachm to 2 drachms (2.-8.) of this stock, 
added to the ounce (32.) of pure glycerin, are sufficiently strong for 
application to the oozing surfaces of eczema rubrum. 

Lassar 1 recommends that the part affected should at first be well 
soaked with antiseptic oil, of which a considerable quantity is absorbed 
by the skin. A muslin bandage, soaked in oil, is then applied, and 
covered with oil-silk. The oil may be rendered antiseptic by the 
addition of 1 to 2 per cent, of carbolic or of salicylic acid, or 1 and 
1J per cent, of thymol. Sometimes the carbolic acid can only be borne 
for a short time, as it will of itself produce eczema. Rape-seed oil may 
be used in place of the more expensive olive-oil; but drying oils, such 
as linseed-oil, are to be avoided, as they may cause inflammation. 
In chronic eczema, especially in infants, and in eczema of the face, 
Lassar recommends an ointment. The formula for an ointment which 
cannot be rubbed off during sleep, in eczema of the face, is: 


R.—Acid, salicylic., 

3ss; 

2 

Zinc, oxid-, 

3VJ; 

24 

Amyli, 

3vj; 

24 

Vaselin., 

3 1 j; 

64 


Wyndham Cottle has employed chaulmoogra-oil, or gynocardic acid, 
in a large number of cases of eczema occurring in persons with delicate 
skins, and over such exposed surfaces as the face, the hands, and the 
arms. In both acute and chronic forms he has employed these sub¬ 
stances in the form of ointment, in the strength of from 15 to 25 grains 
(1.-1.5) to the ounce (32.) of vaselin. The ointment is applied several 
times in the day, and, if possible, is kept in contact with the part on 
rags over which it has been spread. 

Other mercurial preparations than those named above have long been 
in favor for application to localized patches of the disease. Among 
them may be named corrosive sublimate, ammonio-chlorid, iodid and 
biniodid, the two oxids, and the nitrate. 

Calomel, which is exceedingly useful in the strength of from 1 scruple 
to 1 drachm (1.-4.) to the ounce (32.) of zinc, lead, or simple ointment, 
can be often advantageously employed; also as a powder in full strength, 
or diluted with bismuth or with starch. In localized patches of papular 
eczema marked results follow dry dusting of calomel over the part, 
when this dressing can be tolerated, followed by alternate super¬ 
position of neatly adjusted strips of surgeon’s plaster, the whole being 
kept in situ by a bandage. If the itching is alleviated by this dress¬ 
ing, it can be reapplied for a week as soon as it is loosened, when the 
redness and infiltration will be found greatly reduced. 

Other surgical appliances used in the local treatment of eczema are 
Martin’s solid-rubber bandage, Fox’s tubular bandage of rubber, and 
dressings composed of starch, gutta-percha, or plaster-of-Paris, in¬ 
tended to support the extremities when the integument is weakened. 
None of these dressings is equal to rest in the recumbent posture. 
The most useful purpose subserved by rubber in the treatment of 


1 Annal. de Derm, et de Syph., September, 1881. 



332 


DISEASES OF THE SKIN . 


cutaneous affections is to provide an impermeable outer dressing for 
watery and oily applications. Here the mackintosh and the silk pro¬ 
tective of the Lister dressing answer all indications. 

The plaster-mulls of Unna are useful in the management of this 
and other forms of the same disease; the objection to their use in 
America (not applying to Germany and England, where they are most 
in favor) lying in the frequency with which the imported mulls undergo 
chemical changes, rendering them wholly unfit for local use on the 
tender skin. The bassorin pastes lately suggested as vehicles for topical 
medicaments are of considerable value. All the several parasitic forms 
of eczema require treatment directed to the removal of the cause, and 
many of the methods of treatment hitherto employed with advantage 
doubtless owe their efficacy to their action as parasiticides. Many of 
the post-eczematous boils, the mixed forms of eczema impetiginodes, 
and the like , 1 are the result solely of inoculation of the skin with pus- 
cocci, and are to be prevented by complete antiseptic care of that 
organ during an eczematous attack. 

Prognosis. Eczema is an entirely curable disease, but uncertainty 
attends its prognosis as regards the duration of an attack and the 
probability of the recurrence of a relapse. With respect to the ques¬ 
tions most frequently asked, those relating to contagion, heredity, and 
persistent lesion-relics, naturally a favorable response can be made; 
but the fact remains that some forms of the disease are insignificant, 
some persistent, and some particularly liable to relapse from very slight 
provocation. Only after careful weighing of all the conditions exhibited 
by the skin and by the other organs of the patient can a reasonable 
probability as to the future of the disease be estimated. Eczema is a 
disease exceedingly common, and one subject to aggravation by causes 
well-nigh innumerable. Were the physician always in position abso¬ 
lutely to insure his patient the exclusion of all sources of irritation, the 
prognosis would be much more satisfactory. In hospital patients, 
where such control is more perfectly attained, the results of treatment 
may be predicted with some confidence. 

In general, it may be said that acute eczema is more readily relieved 
by proper treatment than the chronic forms of the disease; that eczema 
with a discoverable cause is more manageable than one whose etiology 
is obscure; that eczema of the very young and of the very old is at 
times particularly rebellious; that the non-discharging phases of the 
disease are rather more persistent than those accompanied by secretion; 
that eczema lingering at the mucous outlets of the body (auditory canal, 
nostrils, mouth, nipple, anus, vagina) is more obstinate than when it 
affects the skin of other parts (shoulder, neck, lumbar region); that 
eczema with constant aggravation or complications (fissure of the hands, 
varicose veins of the leg, apparatus for anchylosis of knee) is more 
stubborn in proportion as these complications or aggravations cannot, 
from the circumstances of each case, be set aside; and, finally, that 
an eczema which has long existed, or has repeatedly recurred, as, for 

1 Compare an admirable paper on “ Recent Advances in the Etiology of Diseases of the Skin,” 
hv Walter G. Smith. Dublin Journal of Medical Science, January, 1892. 


INFLAMMA TIONS. 


333 


example, with every season of extremely cold or hot weather, is, after 
relief, very liable to return. Dermatitis seborrho'ica (eczema, sebor- 
rhoicum) affords brilliant results in all well-managed cases. The 
parasitic eczemas are also particularly amenable to treatment. 


Local Varieties of Eczema. 

Eczema of the Scalp. [Eczema Capitis. Eczema Capillitii.] 

When the scalp is affected with eczema the symptoms differ some¬ 
what, according to the age of the patient. In adults the erythematous 
and squamous varieties of the disease are more common ; in infants and 
children the pustular variety. In the former the eruption is usually 
circumscribed and in patches; in the latter it is more diffused. In the 
same proportion, also, the former is generally asymmetrically and the 
latter symmetrically developed. 

In infants and children the pustules rupture early, and their contents 
dry into dirty-whitish, yellowish, or greenish crusts, matting together 
the hairs, thus serving as foci for dust-accumulation and as nests for 
lice, the crusts being superimposed upon a reddish, oozing, pus-covered, 
or occasionally indolent skin, often foul-smelling, and usually compli¬ 
cated by a seborrhea. The so-called “ milk-crust ” is usually a com¬ 
pound of dried pus and altered sebum. The itching is not so intense 
as in some other forms of the disease. Post-cervical, pre-auricular, and 
occipital adenopathy are common, and in strumous children suppura¬ 
tion of the affected glands may occur, though this is rare. The causes 
of this form of disease are evidently associated with local conditions. 
The rapidly growing hairs of the scalp are in intimate association with 
the numerous and large sebaceous glands of the same part, which 
unquestionably respond at times to the physiological stimulus they feel, 
by an exudative process. The acne of the young man whose beard is 
growing illustrates the same fact. Local irritants are not often want¬ 
ing to push the disturbed equilibrium into the scale of disease. 
White calls attention to the common neglect in removing the “ pre¬ 
natal cap of cheesy material,” as well as to rude and unskilful 
attempts to accomplish the same end. Extremes of temperature, fric¬ 
tion, excess, neglect, and absence of endeavor to wash the scalp, all 
these contribute to originate or to aggravate the disorder. 

The affection when complicated or induced by lice is more common 
in children than in infants, doubtless in consequence of the greater 
independence of the former and their gregarious habits. In girls 
with relatively long hair, the ova, or nits, of the parasite are readily 
distinguished, adhering closely to the hairs, and accumulated especially 
about the occipital region. The itching is usually more annoying than 
in pustular eczema not thus complicated. 

The erythematous and squamous forms of the disease, rather more 
common in adults, originate frequently in seborrhea, when scratching 
has been practised or irritant applications have been made. The erup¬ 
tion here usually occurs in asymmetrical patches, or it may be limited 


334 


DISEASES OF THE SKIN. 


to a single patch, tolerably well defined in outline, often upon one 
side of the scalp, not, as in infancy, preferring the vertex. Reference 
is made in the chapter on Seborrhea to a form of eczema of the scalp 
occurring in adults where finger-nail-sized, circular, oozing or slightly 
crusted patches are generally disseminated over the affected surface. 
They result, as a rule, from the scratching of an obstinate seborrhea 
in u nervous” women, and suggest traumatism, in their reddish friable 
crusts, the color being due to exuded blood. 

The diagnosis of these forms of disease has been already considered. 

Treatment. In the treatment of eczema of the scalp in infants 
and children the first indication to be met is the removal of the accu¬ 
mulated crusts. When this removal is harshly accomplished it becomes 
a fruitful source of further mischief; it is, therefore, necessary to pro¬ 
ceed with great gentleness. The thorough softening of the crusts is 
all-important. For this purpose it is necessary to soak them with 
oil and to retain this substance in intimate contact with the scalp. 
Olive or cod-liver oil may be selected, and, if needful to correct the 
odor or for other purpose, 1 drachm (4.) of carbolic acid may be added 
to each pint (512.), with 2 drachms (8.) of the balsam of Peru. A 
neat-fitting skull-cap, constructed of Lister protective or of flannel, 
should then smoothly be applied, and fastened in place by a light ban¬ 
dage, never by elastic-rubber bands. After several hours of soaking 
the crusts should be removed by warm water and spirit-of-soap wash¬ 
ing, and the entire process be repeated until the crusts are completely 
detached. In selecting an article for subsequent medication of the 
scalp it should always be remembered that even infantile eczema will 
proceed to a natural involution if unirritated; hence oleated lime- 
water, or oil of sweet almonds alone, will often answer better than an 
ointment, and, even where there is considerably acuity of the inflam¬ 
matory process, lime-water alone, with possibly a small quantity of 
glycerin added, will be effective. In other cases lime-water can be 
better medicated with calomel or with oxid of zinc. At times, also, 
it is well, even when these applications are kept in contact with the 
scalp, to order that a small pea-sized mass of one of the ointments 
described above, such as benzoated oxid-of-zinc ointment with cold 
cream, or one medicated with a mercurial compound, e. g., calomel, 20 
grains (1.33); or white precipitate, from 10 to 20 grains (0.66-1.33); 
or subnitrate of bismuth, 1 drachm (2.) to the ounce (32.), be 
applied at the time of dressing. This ointment is to be gently 
rubbed in the surface with the tip of the finger, and the skin afterward 
protected with suitable dressing. 

It is rarely needful to cut the hair unless nits be found, though in 
public charities it certainly is a more expeditious method of arriving 
at the end when a nurse has to dress the heads of several children in 
a single ward. In adults, especially in women, the hair should be 
spared, while the patient is warned that the loss of the growth upon 
the scalp may be considerable. Where an obstinate seborrhea is followed 
by an eczema the latter may be succeeded by alopecia ; in the absence 
of seborrhea the hairs are usually reproduced. It is rarely necessary 
to employ the skull-cap in adults, since one can succeed in insuring 


INFLAMMATIONS. 335 

the necessary applications by directing the attention of the patient to 
the necessity of care and thoroughness. 

Lice when present may be destroyed by the application of petroleum. 
After the petroleum dressing nits are removed from hairs which it is 
not desirable to cut with alcohol or with cologne-water. 

As the disease in both classes of patients advances to a subacute or 
chronic stage the treatment may be changed so as to include the various 
stimulating applications already described, such as ointments and spirit- 
lotions containing tar, oil of cade, balsam of fir, pyrogallol, alcohol, 
or sulphur. In the case of infants, however, such stimulating topical 
remedies are very rarely to be employed. An eczema of the scalp that 
has once entered upon resolution, in an infant or a child, should gen¬ 
erally be soothed and protected. 

Many little patients thus affected are in excellent general health, and 
require no internal medication; others demand the interposition of the 
wisdom of the physician to protect them from the ignorance or folly 
of those to whose charge they are intrusted. There is not space for a 
discussion of the pressing questions relating to the nutrition of the 
infant deprived of the breast and starving on the u proprietary” diet 
purchased of a chemist, or an equally vicious aliment compounded by 
lime-water, and imbibed through a tube by which it is flavored with 
India-rubber aud the chemically altered casein of milk several days 
old. Fresh, pure, or sterilized milk, animal broths, and cod-liver oil 
must not be neglected. This diet concerns the health of the child, 
and has indirect connection with the eczema. Among one hundred 
infants dead of artificial foods and marasmus in public charities a case 
of eczema will scarcely be recorded. 

Lastly, patients of both classes are to be saved from mercury, arsenic, 
and the iodid of potassium. 


Eczema of the Face. [Eczema Faciei.] 

Erythematous eczema of the face in adults is projected prominently 
among the varieties of the disease by its uniformity of type. It occurs 
in early and in middle life and in advanced years, and is a particularly 
intractable ailment. In well-marked cases the forehead, cheeks, eye¬ 
lids, and nose of the patient are involved, exhibiting an infiltrated, 
usually dusky red, often symmetrical patch of disease, the affected 
surface being slightly elevated above the level of the sound skin. This 
surface is uniformly smooth and reddened; occasionally, near the root 
of the nose and about the lower line of the forehead, minute, closely 
set papules are visible. Very slight oozing, especially after irritation, 
may be noticed. At the height of the disease, or in its involution, 
there form exceedingly fine scales, which are scarcely perceptibly shed 
from the surface. The eyelids, especially the lower lids in advanced 
years, become puffy. The line of demarcation of the attacked surface 
is uuusually distinct, and rarely invades the scalp-border or the region 
of the beard. Itching is at times intense, the patient bitterly complain¬ 
ing of it, and usually preferring to rub the face with the hands or 


336 


DISEASES OF THE SKIN. 


with pieces of cloth. Sometimes, however, the face is well scratched 
with the finger-nail, and excoriations and blood-crusts disfigure the 
countenance. Patients of intelligence usually describe the itching as 
paroxysmal, and as starting at the root of the nose, whence it travels 
upward over the forehead, and laterally to the brows, often in the 
line of the supraorbital nerves. Certainly at the root of the nose, 
the exudative process is of the most marked character. The eruption 
is seen also in asymmetrically disposed patches of various sizes, with 
islets of sound skin between. In typical cases the hairs of the eye¬ 
brow are reduced to a stubble by constant rubbing. In resolution of 
the symmetrical form this condition of the eyebrows is commonly ob¬ 
served. 

Patients thus affected are often those whose faces have especially been 
exposed to irritation, such as locomotive-engineers, pilots of sea-going 
vessels, mechanics in trades where the hands are soiled with irritants 
and afterward applied to the face, and women spending hours of each 
day over the laundry-tub or the kitchen-stove. In each class the 
operation of the cause is made manifest by the exacerbation of the 
disease after exposure. 

The affection is most commonly mistaken for erysipelas, a disorder 
from which it is readily differentiated by the chronicity of its course. 
The latter feature is particularly characteristic of this form of eczema, 
which is rarely completely relieved after the age of sixty within a 
twelve-month, and which, when it has existed for a long period of time, 
is particularly obstinate under the best treatment, recurring with exas¬ 
perating frequency upon exposure of the face to atmospheric changes. 
The great vascularity, abundant supply of sensory nerves, and neces¬ 
sary exposure of the face, probably explain this peculiarity. In its 
treatment the dusting-powders fulfil an important part. Soothing 
applications should always be first employed; the more stimulating 
applications may be tried later. 

In patients of younger years the face is apt to display vesicular and 
pustular phases of the disease, forms more often of acute eczema, and 
correspondingly more manageable. The itching, and especially the 
burning sensations, are apt to be severe, and crusts rapidly form. In 
infants the picture presented is often that seen in the scalp, except 
that the hairs are not matted into crusts, and there is often a red¬ 
dish blush at the edge of the patch; or, when the crust has been 
removed, a redness of the oozing surface being somewhat more marked 
than the similar patches on the less vascular scalp. The scratching 
in these little patients is severe, crusts being torn off in part or wholly; 
blood-crusted excoriations are common. The area of surface involved 
is in this way clearly extended, sleep is greatly disturbed, and the 
irritability and fretfulness of the child, thus produced, bear heavily 
upon its general nutrition. In severe cases of long standing the mental 
tone of the little sufferers becomes singularly perverted, and their 
character unquestionably changed. The eczema of the cheeks and the 
chin of infants is often due to reflected irritation from eruption of the 
teeth. 

This chain of formidable symptoms well-linked together will often 


INFLAMMA TIONS. 


337 


bid defiance to the most skilled effort to impart ease to the tormented 
skin. In such cases the harness employed by AVhite, of Boston, fills 
an important office: a skull-cap, made of firm old cotton or linen- 
cloth, is closely fitted to the calvarium, and a mask of the same ma¬ 
terial is shaped to the face with exactly placed apertures for the eyes, 
nose, mouth, and ears. This mask is gathered in beneath the chin, 
and laps over two inches at the back of the head; it may be used only 
during sleep, or, in aggravated cases, also during the hours of wake¬ 
fulness. A species of strait-jacket is made by passing the head of the 
child through a hole in the closed end of a small pillow-case, which 
is then drawn down over the body and arms, and the latter confined 
at the sides by stitching the case together between the trunk and the 
upper extremities, or accomplishing the same ends with safety-pins. 
This jacket is finally secured by similar means between the thighs. 
When it is necessary to imprison the lower extremities they are simi¬ 
larly secured by pins within the pillow-case; and the outer edge of 
such trousers can be fastened to the bed or the cushion on which the 
child reclines. Of course, this treatment does not preclude the em¬ 
ployment of the washes, ointments, etc., which are to be neatly applied 
next the skin beneath the “ trousers’’ or the “ jacket.” The result is 
that rest is given to the tormented skin, which is not suffered to be 
exposed to a single scratching even during the dressing of the parts, 
and its natural tendency to repair soon brightens up the case. 

In the treatment of these cases the black-wash and zinc-salve treat¬ 
ment will be found valuable, as also the use of diachylon salve, Lassar 
paste, boric acid ointment, lead-lotions, and glycerole of starch. Van 
Harlingen gives the following : 


-Pulv. zinc, oxid., 

3j ; 

4 

Sevi purificat., 

3ij; 

8 

Adipis, 

3iv; 

16 

Pulv. ulmi flav., 

q. s., 



To protect the face from cold air he also employs j- ounce (16.) each 
of glycerin and gum tragacanth, J drachm (2.) of borax, and water 
sufficient to make a paste. 

In obstinate cases of adults tar should be employed. It is well to 
remember in the management of any case that while a tarry application 
may be well tolerated over one part, as, for example, on the cheeks 
and near the nose, in another part, as, for example, over the eyelids, 
a zinc salve may better be employed in the same individual. 


Eczema of the Lips. [Eczema Labiorum.] 

Reference has already been made to the obstinacy of eczema occur¬ 
ring near the mucous outlets of the body, a result due, probably, to 
the secretion furnished by the adjacent mucous tracts. The lips furnish 
an illustration alike of this pertinacity and aggravation. Their frequent 
motions in mastication and articulation aggravate an eczema, which 
is, moreover, apt to be teased by a no less frequent thrusting of the 

22 



338 


DISEASES OF THE SKIN. 


tongue out of the mouth (where there is no beard) to wet the parts with 
mucus and saliva. One or both lips may be involved, vesicular, pus¬ 
tular, squamous, and erythematous lesions occurring at one point, or 
along the entire line of either, with frequently resulting crusts and 
fissures. The vermilion border of the lips commonly participates in 
the process. The lips become hot, and sometimes much thickened by 
the swelling and infiltration, their mucous faces being rarely implicated. 
Scarlet, dull red, and other peculiarly purplish hues of the vermilion 
border become visible. The parts are more picked than scratched, 
though the itching at times is severe. The pustular and vesicular 
forms are more common in children. The erythematous form, its 
reddened outline roughened by scales, evenly projected beyond the 
vermilion border, is rather an affection of maturer years. In many 
cases the disease is aggravated by nasal discharges which flow over the 
lip, giving the latter an elephantiasic aspect or even the appearance of 
an animal’s snout, a condition noted also in later life. Occurring 
upon lips covered with hairs of the moustache, the disease exhibits the 
usual symptoms of eczema barbae, in some cases the picture is that of 
a typical eczema seborrhoicum. In male patients the pipe, the cigarette, 
and the cigar, as well as the tobacco chewed and expectorated, may 
aggravate the malady. In all cases it is obstinate, and calls for either 
emollient, stimulant, or protective applications. In eczema of the lips 
displaying acute and painful symptoms frequent fomentations of the 
part with soft rags dipped in hot mucilaginous and alkalin waters 
will aid in controlling the swelling and in alleviating the pain. In 
chronic cases, where stimulation is demanded, this can be effected at 
the time of dressing, the parts being subsequently protected by col¬ 
lodion or other material. Carbolic acid and nitrate of silver are often 
needed for such dressing. In eczema of the hairy lip it is often of 
great service to remove the moustache by epilation or by shaving. 

Fox suggests the use of thymol, 5 grains (0.33) to the ounce (32.) 
of cold cream. Van Harlingen applies equal parts of dilute phosphoric 
acid, glycerin, and syrup; and to the outer edge of the lip 2 scruples 
each ^2.66) of zinc oxid and honey, 6 drachms (24.) of the oil of sweet 
almonds, and 2 drachms (8.) of wax. Veiel paints the lips twice daily 
with soft soap. Taylor’s application of tincture of benzoin, each 
ounce (32.) containing from 1 to 2 grains (0.06-0.13) of corrosive 
sublimate, is a valuable solution for painting over the cracks and fissures 
near the angles of the lips. 

The diagnosis is between hyphogenous sycosis, herpes labialis, and 
epithelioma. The first is accompanied by loosening of the hairs, caused 
by a vegetable parasite; the second is vesicular in lesion, brief of dura¬ 
tion, and trivial in severity; the third .is a disease of advanced years 
rather than of early and middle life, and is never accompanied by 
itching, but usually by more or less ulceration. Syphilis is fond of 
the angles of the lips; in most cases, when thus limited, typical mucous 
patches of the mouth can be discovered. 

The lesions of syphilis at the angles of the mouth are seldom linear 
fissures, but are more often irregularly outlined erosions, secreting a 
puriform mucus. Pustules and resulting crusts of the lips and the 


INF LAMM A TIONS. 


339 


nose in female children are often eczematoid features due to the picking 
and scratching solicited by lice upon the scalp. 


Eczema of the Nostrils. [Eczema Narium.] 

Eczema of the nostrils is naturally often associated with a chronic 
coryza. Inasmuch as one of the common symptoms of hereditary syph¬ 
ilis is the “ snuffles” of a child, the physician should carefully 
exclude the possibility of such disorder in every instance when an 
infant with coryza exhibits an u eczema” of the nares or the lips. 
The age of the little patient, an inspection of its anal region (that 
should never be omitted in infantile eczema), and the history of the 
case will throw considerable light upon this important question. 

Whether occurring in the adolescent or the child, the disease may 
linger only upon the alse in the pustular or the squamous form, or 
may block up the nares with crusts. In infants this obstruction 
enforces respiration with an open mouth, and the grasp of the nipple 
by the lips is thus interrupted either by respiratory acts or cries of 
agitation. The Schneiderian membrane participates in the inflamma¬ 
tory process, and pours out its secretion upon the eczematous skin. 
This membrane when inspected is seen to be either raw and succulent, 
or in a condition analogous to that seen in the pharyngitis sicca of 
authors, is dry, glazed, and free from discharge. The nostrils are 
often thickened in consequence of infiltration or are fissured, especially 
at the lines of the nares, laterally and interiorly. In severe cases, 
and when the lips participate in this process, the pouting, swollen, and 
distorted organs suggest the snout of the lower animals. Adults, as 
a result, frequently suffer from coccogenous sycosis and furunculosis. 

Diagnosis. Care should be taken to exclude syphilis in making a 
diagnosis, bearing in mind the fact that the pustular syphiloderm 
(which see) frequently selects the furrow on either side of the nares 
for its evolution. 

Treatment. In treating these cases all crusts should be removed, 
and the parts carefully be protected. Picking of the nose in children 
should be prevented, if needful, by the “ strait-jacket.” Pencilings 
with compound tincture of benzoin, iodized phenol, nitrate of silver, 
or collodion often prove serviceable. 

In softening crusts oil may freely be used. For this purpose the 
warm carbolized spray of the atomizer answers well, medicated with 
resorcin, which may also be efficiently employed for the relief of the 
nasal catarrh, often responsible for the disease in adult cases. Unna 
recommends in such patients drainage-tubes wrapped with lead-oint¬ 
ment mull, and, after the softening of the crusts, painting every second 
day with yellow precipitate ointment. In the same way a weak citrine 
ointment or a white precipitate salve may be used. When the disease 
extends well up the nares Neuman nemploys bougies made by com¬ 
bining 2 grains (0.138) of zinc oxid with 16 grains (1.06) of cocoa¬ 
butter. Hardaway recommends equal parts of cold-cream salve and 
glycerole of subacetate of lead. 


340 


DISEASES OF THE SKIN. 


Eczema of the Ears. [Eczema Aurium.] 

The ears are affected with eczema, both in infancy and in maturer 
years, rather more often in women and children, the disease being 
limited to the whole or a part of the organ, or extending backward 
over the post-auricular region, or downward over the ramus of the 
superior maxilla. The eczema may be acute or be chronic, and may 
originate in seborrhoic eczema of the scalp or the face; in chronic or 
catarrhal discharges from the external auditory meatus; in the growth 
of aspergillus in the same canal; in exposure to temperature-changes, 
especially when aided by high winds; in frostbite; in the irritation 
set up by pediculi and by the auricular rim of the frame of spectacles; 
in the toxic effect induced by the hook of cheap ear-rings and dyed 
bonnet-ribbons; in the traumatism of ear-piercing; and in the habit 
of unnecessarily picking the ear to relieve it of wax or of trifling 
sensations of irritation. 

The pustular and moist forms are common at the superior, inferior, 
and posterior boundaries of the pinna, where a linear fissure is apt to 
form in the line of the angle made by the auricle with the plane of 
the adjacent integument. The motions impressed upon the ear by 
handling it, or by placing the hat on the head and tying hat-strings 
over the ear, always tend to aggravate the disorder. Long hairs worn 
over the ears have a similar effect by the production of friction and 
the retention of heat. The lobules are apt to display the erythematous 
and scaly phases of eczema, becoming infiltrated, and having a de¬ 
formed appearance and lurid red color, the affection pursuing an 
indolent course. The lobules alone of both ears in young women may 
similarly be affected, and may exhibit these phenomena for consecu¬ 
tive years. Often the chronic inflammation lays the foundation for a 
keloid growth, an accident of inflammatory processes in other parts. 

Sometimes the entire auricles present a similar appearance, uniformly 
dark red, infiltrated, alternately weeping and scaling, and projecting 
to a noticeable extent from the side of the head in consequence of. 
their increase in bulk. The itching is usually more annoying than 
severe, being accompanied by a characteristic sensation of tenseness 
and fulness of the part. Like the eczema which occurs at the other 
mucous outlets of the body, the affection in the meatus is particularly 
obstinate when it assumes a chronic form. Symmetry to the extent 
of involving both ears, though commonly to a different degree in each, 
is rather the rule than the exception, and is doubtless due to the simul¬ 
taneous operation of effective causes. 

The diagnosis is between erysipelas, seborrhea (which occasionally 
occurs in the concha of the auricle), erythema simplex and multiforme, 
and dermatitis calorica. The mouth should always be carefully exam¬ 
ined in these cases for sources of trouble. 

The treatment should at first be soothing and protective by zinc- 
salve or diachylon ointment; afterward be stimulating. A firm 
bandaging of the ears to the head may be required to support these 
parts, to prevent irregular pressure (head upon the pillow), and to 


INF LA MM A TIONS. 


341 


secure contact with external medicaments. In chronic cases stimulant 
applications are often well tolerated, and tarry ointments here play 
an important part. Treatment appropriate to the otitis externa or the 
aspergill us may be required. Bulkley recommends a tannin ointment, 
1 drachm of tannin (4.) to the ounce (32.), deeply and thoroughly 
passed into the meatus on a camel’s-hair brush. French authors gen¬ 
erally recommend small tampons smeared with an ointment and left 
in the canal. Burnett employs 2 drachms (8.) of oil of tar to 1 
ounce (32.) of alcohol. Great benefit is derived from pencilling the 
indolent surfaces with solutions of silver nitrate. The intractable 
forms almost invariably affect adults, in whom there is usually a history 
of improvement under treatment, followed by relapse due to exposure 
to wind, heat, cold, or other sources of irritation. 


Eczema of the Eyelids. [Eczema Palpebrarum.] 

In eczema of the eyelids the free edges of the eyelid, or the skin over 
the orbital margin of the tarsal cartilage, may chiefly be affected; and 
these parts, both in children and adults. When the free edge of the 
eyelid is involved there is present a species of coccogenous sycosis, 
the hair-follicles becoming inflamed and furnishing a purulent discharge 
which mav agglutinate the eyelids. The latter are thickened and swol¬ 
len, become the seat of a moderate itching, are picked rather than 
scratched, and exhibit minute crusts between, or glued to, the hairs. 
The disorder is often accompanied by a seborrhea of the Meibomian 
follicles, and is described by oculists under the designation of u bleph¬ 
aritis” or “ tinea tarsi . 99 Inasmuch as the facial expression is quite 
characteristic when the eyelids are thus involved, patients exhibiting 
this form of eczema are usually set down as “ scrofulous,” though it 
occurs in many individuals with no other sign of struma, and eczema 
surely is not such a sign. 

Fissures occasionally form at the commissure of the eyelids. The 
disorder may complicate eczema of other parts of the face. In 
erythematous eczema faciei of adults there is usually swelling with 
puffiness, especially of the lower eyelid. The conjunctiva may or may 
not he implicated. A chronic granular condition of the eyelids is not 
noted so frequently as might be suggested by a priori reasoning. 

The edges of the eyelids should carefully be cleansed with a weak 
alkalin solution and a soft camel’s-hair brush whenever the eyelid is 
involved, and theu as carefully be dried and anointed with cold cream. 
In acute cases the closed eyelids may be frequently bathed with warm 
alkalin solutions; and strips of soft lint, soaked in the same material, 
or a very dilute glycerin or carbolic-acid solution, may be laid over 
the closed lids for as long periods during the day as they are com¬ 
fortably tolerated. In chronic cases red-oxid-of-mercury ointment, 
from 1 grain to 10 (0.066-0.66) to the ounce (32.), with or without an 
equal quantity of salicylic acid, has always been held in high esteem. 
Oculists, in the treatment of this affection, are fond of using an oint¬ 
ment of yellow oxid of mercury, one to three grains to the drachm 


342 


DISEASES OF THE SKIN. 


(Pagenstecher). In place of these mercurials the unguentum hydrar- 
gyri nitratis, one part to six of cold cream, may be applied, or resorcin 
one part to fifty of cold cream salve. Epilation of the eyelashes may 
rarely be necessary. Pencillings with solutions of the nitrate of silver 
in various strengths are also useful in chronic cases, but these solu¬ 
tions must carefully be confined to the eyelids, and not be suffered 
to come in contact with the conjunctiva. Excessive use of the eyes 
must be prohibited. 

Diagnosis. In the diagnosis care must be taken to exclude syphilis, 
lupus, and pediculi. Piedra of the eyelashes must not be overlooked. 
Instead of the ordinary nits of the lash, there are in such cases jet- 
black, small pin-head-sized masses of ivory-like hardness attached to 
the hairs. 


Eczema of the Beard. [Eczema Barbee.] 

Eczema may involve the region of the beard only, or it may spread to 
this part from those in the vicinage, or it, finally, may extend from the 
beard to other parts of the face. The first is common, and furnishes, 
perhaps, the best type of the disease; the second is also common, but 
usually is subordinate in importance to other trouble of the facial region ; 
the last is decidedly the rarest. It is indeed a matter of surprise that 
an eczema should, as it often does, endure for years exclusively limited 
to the region of the beard. 

This fact furnishes a convincing argument in favor of the local origin 
and of the frequency of local sources of aggravation of eczema. 
Rarely will one see a picture more suggestive to the uneducated eye, of 
“ scrofula’’ or “ humors of the blood’’ than the face of a middle- 
aged man, with long-standing eczema of the entire region covered by 
the beard. 

The hairs are thinned, and fail to hide completely the reddened sur¬ 
face beneath, covered here and there with pustules or the floors of 
broken pustules, dried inflammatory products, yellowish and greenish 
scales and crusts. Beneath the crusts the surface is smooth, not lumpy 
as in hyphogenous sycosis. The hair-follicles are not solely involved, 
as is the case in the coccogenous form of that disease, but evidently 
they and also the integument between them are involved. In recent 
eczema the hairs are not loosened in their follicles, but in chronic cases 
such loosening unquestionably does occur, and there is a true defluvium 
capillitii. The disorder is evidently one primarily involving the <*kin 
of the region of the beard, and secondarily the hairs, extending 
smoothly over that surface, as smoothly as an eczema on the cheek of a 
woman. There is commonly a certain degree of symmetry, to the 
extent at least of involving the beard in different degrees on both 
cheeks at once, or the chin on both sides; often the symmetry is 
perfect. This symmetry is rare in the several sycoses of the same part. 

The disease is accompanied by itching, rarely so severe as upon the 
smooth parts of the face, is particularly obstinate, and is extremely 
disfiguring. When extending into the region of the beard from other 


INF LAMM A TIONS. 


343 


parts it is usually associated with eczema of the ears. When limited 
to the region of the moustache it may be connected with an eczema 
of the nares and a chronic nasal catarrh, or be a symptom of seborrhoic 
eczema. 

The explanation of the obstinacy of eczema of the region of the 
beard is to be found in the hairs which cover it. Whether the hair 
be long or short, feeble or strong, each hair during the twenty-four 
hours acts to a certain extent as a lever in motion upon the portion of 
the integument iu which it is implanted. In conditions of health the 
skin tolerates well this motion; in disease it becomes a positive source 
of trouble. Multiply by thousands the impression produced upon the 
healthy skin when a single hair or a group of hairs is moved by a 
strong current of air, by the fingers, by a brush, or by any other 
externally operating cause, and some idea may be had of the extent to 
which this force may become effective. But the best evidence of this 
irritation is to be found in the results which follow the removal of the 
beard. Clipping short the hairs of the face will not answer, though 
this is generally preferred by the patient as exposing to a less degree 
the unsightly surface beneath. Nothing short of epilation or of shaving, 
and continual shaving every second day, will effect the desired result 
in chronic cases. As soon as the disease is reduced practically to an 
eczema of the non-hairy parts it improves in proportion to its distance 
from the mucous outlets of the body. When limited to the bearded 
cheeks the most obstinate cases may in the course of a single month 
be robbed of one-half their unsightliness. It may be needful to employ 
the usual methods—oil, hot water, and soap—to remove the crusts 
before the first shaving; and any imprisoned pus should be evacuated. 
The patient should be encouraged by reminding him that usually it is 
but the first step which costs, each succeeding removal of the beard 
being accomplished with greater comfort to himself physically and 
mentally. After each epilation or shaving the skin should be bathed 
iu water as hot as tolerable, and, if at night, a lotion or an ointment, 
or the latter after the former, may be used. The salves most useful 
for this purpose are sulphur, 1 drachm to the ounce (4. to 32.); 
diachylon ointment with salicylic acid, 5 to 10 grains to the ounce 
(0.33-0.66 to 32.), and zinc or tar ointment. Rarely, the surface 
requires painting with weak solutions of nitrate of silver. Best of all, 
however, is a dusting-powder, and, as soon as practicable, the patient 
should limit himself to this application. The shaving should be 
continued for months after the disease is at an end. It is, indeed, 
surprising to note in severe cases how quickly the “ scrofulous” look 
disappears, and the evidences of a “ humor of the blood” are no more 
visible in the face. The longer the limitation of the disease to the 
region of the beard, the more brilliant, as a rule, is the result. It is 
not often necessary to resort to tarry applications in this form of 
the affection. When complicated by eczema of the post- or the infra- 
auricular region stalactite-shaped crusts depend from the infiltrated 
lobule in consequence of the continuous drip of serum from above. 
Eczema of the region of the adjacent whisker is less readily managed. 

Flat epitheliomata of the bearded cheek are not to be confounded 


344 


DISEASES OF THE SKIN. 


with eczema barbae. It should be remembered, also, that the age of 
the patient, the career of the disease, the possible eversion of the neigh¬ 
boring eyelid, or agglutination of the adjacent lobe of the ear, dis¬ 
tinctly high elevation, or ulceration of tissue, absence of itching, and 
marked localization of the disease, are all characteristic of this form 
of carcinoma. 


Eczema of the Genital Organs. [Eczema Genitalium.] 

In eczema of the genital organs the disease is remarkable for the 
severity of the subjective sensations it occasions, for its tendency to 
persistence, recrudescence, and nocturnal exacerbation, and for the 
liability to production of the sexual orgasm by the act of scratching. 
In men the surfaces most often involved are the anterior, posterior, or 
lateral faces of the scrotum where they meet the thigh, though the 
surface of the penis, as also that of the pubes and the perineum, may 
be involved. In women the labia majora, more rarely the labia minora 
and vestibule of the vagina, are affected, with occasionally extension 
of the disease to the same contiguous parts as in men. 

Eczema thus located is, as a French writer has well said, ‘ ‘ a dry 
disease in a moist locality.” Vesicular and pustular forms are much 
rarer than the erythematous, the papular, the papulo-squamous, and 
the erythemato-squamous. In women the moister forms are more 
frequent, doubtless because of the wider mucous outlet and the more 
extensive mucous tract in the vicinage. The labia are then heightened 
in color, oedematous, agglutinated by crusts, and often torn viciously 
by the finger-nails. Blood-crusted excoriations are seen in most severe 
cases. An eczema intertrigo at the labio-femoral angle is common. 
Over the whole may be poured the normal or pathologically altered 
secretions from uterus or vagina. The disease, however, is sufficiently 
common after the menopause, when there is physiological atrophy of 
the uterus. 

The typical disease in men is recognized in the thickened, reddened, 
perhaps slightly scaling integument of the scrotum, which may also 
be fissured, excoriated by the fiuger-nails, or covered by blood-crusts. 
Torn papules, even tubercles and nodose swellings often closely packed 
together, may be seen, with a peculiarly lurid, even purplish hue. In 
exaggerated cases the infiltration is so great as to deform the parts, 
increasing the thickness and deepening the normal furrows of the 
scrotal integument to many times its normal dimensions, producing 
thus an elephantiasic appearance. In eczema of the penis the prom¬ 
inent symptoms are also oedema, itching, and redness with slight 
scaliness. 

In both sexes, as before stated, attempts to relieve the itching 
are often as severe and prolonged as they are ingenious. Commonly 
no relief is obtained until a serous sweating or weeping of the thick¬ 
ened tissues is induced by the friction. Inasmuch as the latter in 
severe cases is frequently repeated, the physical dangers are obvious. 

Apart from this, however, the disorder has a marked tendency to 


INF LAMM A TIONS. 


345 


disturb the mental tone and the general health. Shame deters many 
from seeking speedy relief, so that cases of long standing are those 
more commonly registered by the physician. Though entirely uncon¬ 
nected with venereal disease of any kind, there is, for the many, a 
special dread of an eczema of these parts, precisely because of its 
location. With sleep disturbed, the mind agitated, and the nervous 
system teased by an intolerable pruritus, one can scarcely wonder at 
the eloquence with which many patients describe their sufferings. It 
is a disease of middle life and of advanced years. It is rare to see a 
well-marked, obstinate case in a child. 

Etiology. The causes, exciting and aggravating, of eczema of the 
genital region are to be sought in heat, moisture, and friction. These 
primary factors are favored—first, by the effect of gravity, the organs 
in question being situated, when the body is in the erect position, at 
the inferior apex of the double cone forming the trunk, and being 
thus subject to the force of gravity; second, by the arrangement of 
the clothing in both sexes, by which heat and friction effects are height¬ 
ened; third, by uncleanliness, the secretions and discharges from the 
adjacent mucous tracts being suffered to accumulate upon the person; 
fourth, by a long list of sexual errors which operate by obstructing 
what may well be termed the “sexual ebb,” that is, the natural reflux 
by which each periodical physiological congestion of these organs is 
by a natural process relieved. That the skin of these organs partici¬ 
pates in such periodical congestion is a fact demonstrable to the eye. 
The abundant supply of blood-vessels, lymphatics, and nerves to the 
parts furnishes all necessary elements for explanation of the formid¬ 
able series of symptoms often displayed in eczema genitalium. 

In many eczemas of the surface, especially of the genital organs, 
the urine will be found to contain albumin or sugar, and these condi¬ 
tions have been supposed to lie at the root of the eczema. The diet 
for the eczematous patient with saccharine urine is of prime importance. 
In some cases, however, the eczema causes the elimination of the sugar 
or the albumin, and not the reverse. Sugar and albumin are known 
to be producible in urine by external irritants, among which are 
cutaneous diseases. Merely varnishing a portion of the skin has been 
followed by these effects. If a patient with saccharine urine and 
severe genital eczema can be kept in bed, in the recumbent position, 
for a few days, while any soothing application productive of comfort 
is continuously applied to the tender and excoriated surface, the sugar 
will often rapidly disappear from the fluid excreted from the kidneys. 
These renal symptoms are in part reflex, resulting from the extraor¬ 
dinary irritation of the nerves distributed to the involved surfaces. 

The so-called diabetides genitales of French authors include some 
genital eczemas occurring in diabetic patients. But it is certain that 
many cases of very extensive and severe eczemas of the genital region 
in both sexes occur in patients in whom the most careful and repeated 
examination of the urine fails to reveal traces of sugar. The practi¬ 
tioner is urged never to omit such examination in his treatment of a 
typical case. 

Patients exhibiting genital eczema with glycosuria may distinctly 


346 


DISEASES OF THE SKIN. 


be separable into two classes. The first and commonest class includes 
those patients presenting such marked physical symptoms that the 
urine may be suspected before chemical examination. These patients 
are all extremely fleshy women given to an excessive consumption 
of beer. In such patients the sugar decreases pari passu with the 
eczema, if the beer is withheld and the local irritation is judiciously 
treated. In a second and much graver class of patients, also chiefly 
women, there is a diabetic history (often also of pulmonary tubercu¬ 
losis), and the genital eczema is manifestly an epiphenomenon. These 
patients are rarely obese, usually the figure is that of a slender and 
delicate woman; there is little, if any, use of alcoholic beverages of 
any kind; and the local eczema is trifling in features as compared with 
that above described. In these cases, too, under the influence of an 
appropriate dietary and local management the geuital eczema subsides, 
but the glycosuria persists often to grave issues. 

The treatment is to be conducted on the general principles heretofore 
enunciated. Sponging of the genital region with alkaline water as 
hot as can well be tolerated, followed by the blander oils and ointments 
at night, and the use of antipruritic dusting-powders in the daytime, 
must not be omitted. In eczema of the scrotum a suspensory ban¬ 
dage lined with lint which is wet with a lotion, smeared with an oint¬ 
ment, or thoroughly covered with a powder, can usually be employed 
to good advantage. The habit of scratching must be broken up at 
all hazards. In chronic cases the treatment by soft soap and diachylon 
ointment will be found useful. Caustics, solutions of mercuric bi- 
chlorid and other mercurials, carbolic acid, and especially the tarry 
compounds, are often necessary. 

Finny, of Dublin, uses the following formulae, which are useful 
in allaying the irritation: 


R.—Liniment, calcis, 

f 3 iv ; 

128 


Belladonn. extr., 

gr. xij ; 


80 

Zinci oxid., 

; 

8 


Glycerini, 

Wj ; 

8 


Aq. calcis, 

f J;iv; 

128 

M. 

Sig.—Lotion to be applied at night after bathing the parts in 

hot water. 

R.—Lin calcis, 

f,liv; 

128 


Acid, hydrocyanic, (dil.), 

f 3j; 

4i 


Liq plumbi subacetat., 

f 3 ii; 

8 


Glycerini, 

f 3 ij ; 

8 


Aq ros., 

ad f 3 viij ; 

256 

M. 


Sig.—Cream, for application on strips of old linen. 

The Lassar paste may be used with advantage. 

Exceedingly obstinate eczema of the pubic region is benefited by 
shaving and subsequent appropriate treatment. When complicated 
by intertrigo the latter condition requires special relief by the interpo¬ 
sition of soft lint spread with an ointment. 

The diagnosis of eczema of the genital organs is between ringworm 
of the genitals, acne, pruritus, pediculosis, the venereal disorders, and 
herpes progenitalis. The first named may occur alone, or may induce, 
or may be grafted upon the eczema. Ringworm may be recognized 
by the discovery of the trichophyton, and is clinically distinguished by 



INF LAMM A TIONS. 


347 


the crescentic edge of the spreading patch, with its convex border 
looking away from the genital centre. The “ follicular vulvitis ” of 
gynecological authors is a genital acne, and is manifestly limited to 
the glands and the periglandular tissues. The same is true of bromin 
and iodin acne, which may be developed in the same situation in both 
sexes. Genital pruritus may beget an eczema by scratching, but it is 
accompanied by no proper skin-lesion. The pubic louse is visible to 
the eye, as are also its reddish excreta and nits. The ulcers and 
sclerosis of chancroid and primary syphilis are not accompanied by 
pruritus, and, though occasionally multiple, never exhibit diffuse patches 
of disease. Syphilodermata are recognizable by their characteristic 
features and the history of an infectious disease. In herpes progeni- 
talis there are precedent burning, smarting, or neuralgic sensations, the 
occurrence of vesicles or groups of vesicles (lesions rare in eczema of 
the genitals), and frequent limitation of the disorder to the mucous 
surfaces or to the muco-cutaneous lip by which such surfaces are 
bounded. In eczema these boundaries are usually respected, and the 
disease is much more strictly cutaneous. 


Eczema of the Anus and Anal Region. [Eczema Ani.J 

Eczema of the anal region, in its etiology and characteristics, is 
closely allied to the same disease in the genital region. The presence 
of ascarides and hemorrhoids occasionally induces or aggravates the 
disorder; though this is rarer than is commonly supposed, since multi¬ 
tudes of men and women who suffer from piles never complain of 
eczema. The eczema may occur in erythematous, squamous, or pap¬ 
ular form, in the order named; thus exhibiting here, as in the genitals, 
“ a dry disease in a moist locality.” 

The redness, infiltration, and itching may be limited to the verge of 
the anus, radiate from the latter in stellate lines, creep upward between 
the nates in the cleft, sweep forward over the perineum to the genital 
region, or extend laterally with intermediate intertrigo over the inner 
face of each thigh. Rarely the buttocks are covered with the same 
lesions. Fissures are apt to form about the anal orifice. 

This disease is common in infancy, where want of care in the removal 
of the napkin is a fertile source of mischief; and also in middle life 
and in advanced years, when it becomes particularly intractable. The 
itching is intense in the latter class, with frequent nocturnal exacerba¬ 
tion. Unfortunately the scratching is often reflex, and is practised 
during the unconsciousness of sleep, from which the patient is often 
aroused by his or her manipulations. Pollutions fully recognized, or 
occurring during profound sleep, or, more usually, in states of semi¬ 
consciousness, complicate certain cases; defecation becomes painful. 
The harassed nervous system of the sufferer is often in a deplorably 
wretched condition. In cases of long standing the usual congested, 
thickened, infiltrated, and almost elephantiasic appearance of the skin 
is presented, with exaggerations of the natural furrows and occasional 
fissures. The part may simulate in aspect the formidable conditions 


348 


DISEASES OF THE SKIN. 


discovered in passive pederasty. Excoriat’ons are common around the 
anal verge. 

Treatment. In the treatment of these cases the use of very hot 
water hy sponging, and the subsequent application of ointments, have 
yielded the best results. In the case of infants dusting-powders 
and the blander ointments are alone to be employed; in adults, espe¬ 
cially in chronic cases, tarry applications are especially valuable. 
Here the Lassar paste may be applied or the tincture of tar be freely 
painted over the surface, or there may be used one of the tarry oint¬ 
ments, such as the Wilkinson salve, of sufficient firmness to retain its 
form as an unguent when subjected to the heat of the part. Caustics 
are useful when there are fissures. Corrosive sublimate, | to \ of a 
grain (0.033-0.016 to 4 ounces (128.) of milk of almonds; Squire’s 
glycerole of plumbic subacetate, J drachm (2.) in 2 ounces (64.) of 
glycerin and water, or, as a substitute for the latter, soft soap and 
diachylon plaster, are here of special service. Van Harlingen recom¬ 
mends almond oil containing 20 per cent, of carbolic acid. When 
defecation is painful the stools should be semi-liquid in order to insure 
non-aggravation of the local disorder, not, it need scarcely be remarked, 
with a view to eliminating any materies morbi by purgation. Small 
tampons of cotton may be smeared with an emollient ointment, and 
gently be inserted for a short distance within the anus. Tincture 
of benzoin, one part to ten of vaselin, may be used for this purpose. 
Kaposi recommends cocoa-butter suppositories, containing zinc oxid 
with belladonna or opium. When complicated by true fissure of the 
anus the sphincter ani must be stretched or divided, or dilated with 
medicated bougies. 

Besnier recommends the use of a clyster after each bowel-movement, 
the fluid being retained for only a short time. At night a cataplasm 
is applied. The parts are frequently washed with tepid water, and 
the anal tampons are smeared with coca'in. During the day oxid-of- 
zinc salve, 30 grains (2.) to the ounce (32.) of vaselin, is applied, and 
the parts are also thoroughly sprinkled with, equal parts of zinc oxid 
and subnitrate of bismuth in fine powder. Collodion medicated with 1 
to 3 per cent, of salicylic acid, and lotions containing 1 scruple (0.666) 
of nitrate of silver to the ounce, are of great value in many cases. 

Van Harlingen suggests after the use of the hot bath, with the addi¬ 
tion of starch and glycerin, an ointment composed of one part of cod- 
liver oil to two parts of suet. Veiel prefers the cautious use of 
chrysarobin to tar, employing the latter either in the form of spirits 
or as tar diachylon, one part to twenty, gradually increased in strength. 
Carbolic acid and glycerin, a few drachms of each to the pint of elder- 
flower water or of almond emulsion, are specially indicated in fleshy 
women when the disorder, as is often the case, is complicated with 
intertrigo. 

The key to most cases of anal eczema is to be sought in the dietary. 
This disorder, in adults particularly, is apt to be a significant symp¬ 
tom of gout, and without the dietetic and medicinal treatment of that 
condition no local applications avail. Tobacco and alcohol are invari¬ 
ably to be excluded in the case of patients of this class; and alkalies, 


I NFL A MM A TIONS. 


349 


colchicum, and salicylates are often needed. It is in these manifesta¬ 
tions of eczema that health-resorts furnish their best results, necessi¬ 
tating and inviting, as they often do, an out-door life, an appropriate 
regimen, and an avoidance of stimulants. Even in children and infaijts, 
when there are no ascarides in the rectum or the vulva, the dietetic 
management of the patient should never be neglected. 


Eczema of the Nipple and Breast of Women. 

[Eczema Mammae.] 

Eczema of the mammary region is common in nursing-women from 
either the irritation produced by the mouth of the infant, or, more 
commonly, in consequence of a galactorrhea. Eczema intertrigo is 
common below and between the breasts. The eczema here is vesicular, 
erythematous, or squamous in form, with fissures of the apex, the side, 
or the base of the nipple. The serous ooze from the infiltrated areas 
dries as usual into light-colored crusts. There are the characteristic 
burning and itching. The disease may occur on one or both breasts, 
and especially with a galactorrhea in the summer, may spread exten¬ 
sively, covering both breasts, the surface of the belly, and the inter¬ 
mammary region. The circumscribed forms occur also in pregnant or 
in unmarried women, and are to be distinguished from scabies, which 
in women is apt to occur upon the breast. 

“ Paget’s Disease of the Nipple (“ Malignant Papillary Der¬ 
matitis,” so-called “ Eczema ” of the Nipple and Cancer of the Breast) 
is designated by Thin 1 as a destructive or malignant papillary derma¬ 
titis. The mammary tumors here formed are found to originate in the 
epithelial lining of the lactiferous ducts, the elements of which undergo, 
at an early period of the disease, a cancerous transformation. Clinically, 
there is usually observed in Paget’s disease a sunken nipple, its site 
occupied by a bright red or livid infiltrated patch of distinct outline, 
differing thus from the irregular definition of the contour of the eczem¬ 
atous area. 

In all cases of subcutaneous tumor or coincident axillary adenop¬ 
athy the physician should especially be careful in the matter of prog¬ 
nosis. 

Attention has been attracted to this form of epithelioma of the 
nipple and its areola, eczematous in appearance for only a brief period 
of its career, by contributions to the subject made by Darier and 
Wickham. These gentlemen would range Paget’s disease with mol- 
luscum epitheliale and other disorders, as a group to be classed under 
the title of the 11 psorospermoses.” The parasite to which this name 
refers is of the order of the coccidice , or psorospermice , which these 
observers have recognized in microscopic examination of scales removed 
from affected areas of the skin. The parasites strongly resemble epi¬ 
thelium and are claimed to reproduce themselves by dehiscence and 


1 London Lancet, American edition, June, 1881, p. 533. 


350 


DISEASES OF THE SKIN. 


subsequent dissemination through the surrounding tissue. Other obser¬ 
vers, however, have failed to differentiate the germs described from 
epithelium undergoing metamorphosis in inflammatory and other 
changes, and the conclusions on which it has been sought to establish 
a class of psorospermoses are as yet far from general acceptation. 
Paget’s disease is more fully described in this treatise among the epi- 
theliomata; it is sufficient here to call attention to the important fact 
that a fairly well-defined eczematoid patch, surrounding the areola of 
the nipple or that organ only, with infiltration, itching, and possibly a 
fissure of the nipple, or a crust covering a superficial erosion, may be 
the sign of an epitheliomatous change already advanced either in the 
affected part only or deeper in the galactiferous ducts of the breast 
itself. 


The treatment of mammary eczema is in general that described above. 
In severe cases with galactorrhea nothing short of weaning the child 
and a cessation of all demands upon the breast will insure relief. 
Every effort should be made in milder cases to avoid this dernier re-wort. 
At first, scrupulous care; pencillings of fissures with a crayon of silver 
nitrate or with tincture of myrrh; gentle anointings with emollient 
zinc, thymol, or carbolic-acid ointments, which should carefully be 
washed off before the child is put to the breast; and, finally, dusting- 
powders, with soft lint retained between and beneath the breasts, are 
measures to be tried. Later the sublimate solutions, diachylon oint¬ 
ment, or naphtol (2 per cent.) in alcohol, may be employed. Veiel 
recommends the application to all fissured nipples of Lister’s borax 
salve: 


R.—Acid boracic. subtil, pulv , 
Cerse alb., 

Paraffin, \ 

01. amygdal., f 


aa gr. xv; 
aa g ss; 


1 


2 


M. 


Fournier recommends a breast-plate of caoutchouc. When the 
disease is limited to the nipple and areola in nursing-women the 
glass and rubber apparatus sold in the shops may be tried in the hope 
of saving the nipple from mouth-contacts in nursing. Sometimes they 
answer admirably; often they utterly fail. 

Paget’s disease of the nipple should be treated as a carcinoma; 
eventually removal of the breast may be required. 


Eczema of the Umbilicus. [Eczema Umbilici.] 

This local variety of the disease is briefly described in the chapter 
devoted to Seborrhea. In most cases it is either induced or is aggra¬ 
vated by a seborrhea fluida, which gives origin to the peculiarly nau¬ 
seating odor characteristic of the disease. Generally a reddish and 
infiltrated, more or less annular patch surrounds the umbilical depres¬ 
sion, which may be filled with crusts. Syphilodermata, pediculosis, 
and scabies in women are to be carefully excluded in the diagnosis. 

Treatment. Liquor sodse chlorinatse, carbolic-acid solutions, and, 
in chronic cases, iodized phenol will be required in its management. 



INF LAMM A TIONS. 


351 


Care should be taken that the dressing of the navel in the newborn 
infant, the improperly adjusted apparatus for retention of an umbilical 
hernia, and the corsets or “ uterine supporters” of women, do not 
occasion or aggravate the disease. 

Anderson reports that in typical cases, especially of those affected 
with scabies, the navel is swollen and projects in the form of a small 
tumor. 


Eczema of the Superior and Inferior Extremities. 

[Eczema Membrorum. Eczema Crurale.] 

The flexor surface of the extremities, especially in the vicinity of 
the joints, are particularly prone to exhibit symptoms of this disease. 
With these surfaces should properly be included the axillary and ingui¬ 
nal spaces. In all such localities the alternate tension and relaxation 
of the integument serve, when the limbs are in motion, to increase the 
pruritus, and, correspondingly, to aggravate the disease. Often a 
certain proportion of symmetry can be perceived, the two popliteal 
spaces, for example, being simultaneously affected, though each in a 
different degree. The parts most favorable for the complications of 
intertrigo are those nearest the trunk, where the moisture and heat are 
greater, as the groins and the axillae, while the elbow and popliteal 
spaces are more frequently dry, exhibiting papulo-squamous ridges in 
lines at right-angles to the axes of the limbs, with hyperemic patches 
on either side. 

Upon the legs, where the force of gravity is more potent than in 
other parts of the body, exaggerated forms of eczema are found com¬ 
plicated with varicose veins and cedema, with dense infiltrations and 
indurations. In ancient cases the frequent elephantiasic aspect is sig¬ 
nificant, one limb being several inches larger in circumference than its 
fellow, and covered from knee to ankle with enormous patches of eczema 
rubrum of an intensely angry appearance, moist and crust-covered. 
The skin is dry, glazed, and of a lurid reddish hue; or is dry, horny, 
and ridged with irregular projections surmounted by scales resembling 
the rough bark of a tree; or, again, with or without oedema, is tense, 
inelastic, seamed with scars of old varicose ulcers, and deeply and 
irregularly pigmented, a condition with great difficulty distinguished 
from syphilitic ulceration of the same region. At its onset eczema 
of these parts may assume any one of its known forms. In infants 
in long clothing, where the lower extremities are subjected to a higher 
temperature than in adults, the vesicular and pustular forms are 
common. The exceedingly obstinate forms of eczema of the legs, 
especially those complicated with varicose veins, are, of course, chiefly 
encountered in middle life and in advanced years. 

The diagnosis is, in general, to be established by considering the 
points heretofore discussed. The chief difficulty lies in distinguishing 
the eczema associated with ancient varicose cicatrices of the leg from 
syphilitic scars of the same locality that have resulted from degenerat¬ 
ing tubercular syphilodermata or from gummata. In some cases, when 
no distinct history can be obtained, there will be a necessary doubt, as 


352 


DISEASES OF THE SKIN. 


the force of gravity upon the vessels, even without varicosities, pro¬ 
duces certain common features, notably deep pigmentation, in both 
classes of cases. In women the sexual history is all-important, includ¬ 
ing the order of abortions, miscarriages, and viable infants. In both 
sexes the discovery of other lesions, and especially of characteristic 
cicatrices elsewhere, must be attempted. It will be remembered that 
the syphilitic ulcer tends to the shape of a circle or a segment of a 
circle, and though occasionally existing as the sole lesion upon one leg, 
it is frequently multiple, or may involve both extremities, the pigmen¬ 
tation in old cases occurring chiefly at the periphery of the scar. Very 
extensive pigmentation about ancient cicatrices, especially disposed 
between irregularly defined scars, is commoner in eczematous forms, 
as the pigmentation due to syphilis, though long-lived, is yet the more 
ephemeral. With periosteal nodes the diagnosis is clear. 

Treatment. The best dressing adapted to the larger number of 
cases of eczema of the lower limbs is, after disinfection of the surface 
and the application of a Lassar or other well-selected unguent or paste, 
the dusting of the whole area with boric acid, over which may be 
neatly applied, if desirable, a cheese-cloth bandage. Often, however, 
this bandage may be dispensed with, as in both sexes a woman’s long 
stocking, made of thin and light material, such as is used in the sum¬ 
mer season, and always of white or undyed cotton, may be drawn over 
the limb. Over this stocking may be applied, for the purpose of support, 
either a flannel bandage cut on the bias, which can, as a rule, be applied 
without especial skill by the inexpert, or in chronic cases that will 
tolerate it an elastic bandage, the inner white stocking being changed 
with each dressing. In the case of male patients it is often desirable 
that the man’s “ sock ” be drawn over the long white stocking below. 
In this way support without compression (which is the essential point) 
may be secured. 

The general treatment of eczema of the extremities does not differ 
from that described above, except as regards the indications to be met 
relative to support of the parts, thus counteracting the effect of gravity. 
Excellent results may be obtained by the use of the pure-rubber ban¬ 
dage, applied immediately next the skin, especially in cases compli¬ 
cated by oedema, ulceration, and venous varicosity. The method of 
applying the well-known Martin bandage is generally familiar to the 
profession; for details respecting its availability in eczema of the leg 
the reader is referred to the essay on “ Eczema and its Management,” 
by Bulkley, of New York, 1 who is enthusiastic in its praises. 

The above treatment, however, deserves only subordinate rank in 
comparison with the essential rest of the affected limb in the horizontal 
position. With a grave eczema of the lower extremity this rest should 
be enforced; and patients whose limbs have proved rebellious under the 
rubber may thus be relieved. The local applications to be made mean¬ 
while are those adapted to the particular features in each case present. 

To a less degree the same necessity for rest may be said of the arms. 
In these localities it is rarely necessary to resort to elastic pressure. 


1 G. P. Putnam’s Sons, New York, 1881. 


INFLAMMA TIONS. 


353 


In all cases, however, a neatly applied bandage over the dressings will 
provide for pressure and support, and will generally contribute to the 
comfort of the patient. A favorite dressing in dry, papular, erythem¬ 
atous, and squamous patches of the disease, is applied as follows : 

The parts are bathed with hot borated water for several minutes 
until the itching is relieved, and then are carefully and thoroughly 
dried. The patch is then completely covered with a dusting-powder, 
which, according to the indications of the case, is either emollient, 
astringent, or stimulating. Finely powdered tannin with French chalk, 
or boric acid and starch, or bismuth, zinc, and starch may thus be used. 
Over the whole strips of cheese-cloth are superimposed. A snug- 
fitting rubber or flannel bandage cut on the bias encompasses the whole. 
The dressing is left in situ as long as it is comfortable, often for two 
or three days, when it can be removed. In properly selected cases 
the itching is relieved, the infiltration is reduced, and the patch soon 
loses its hyperemic aspect. Occasionally no other treatment will be 
required. 

Nor should it be forgotten that, with care and patience, the starch 
bandage of the leg, the plaster-of-Paris dressing over folds of Canton 
flannel so arranged that it may be removed at pleasure in the manner 
in which it is used by some surgeons in treatment of diseases of the 
joints, these and other immovable dressings may accomplish even more 
in obstinate cases than elastic apparatus. 

For the exudative phases of eczema of the leg, the forms so often 
seen here of eczema rubrum, the gelatin medicated plaster meets the 
indications well. Morrow makes this plaster by adding two hundred 
and fifty parts of glycerin to one thousand of gelatin, and two thousand 
of water medicated with 10 per cent, of oxid of zinc and 1 per cent, 
of carbolic acid. It may be left in situ several days, and furnishes a 
smooth, elastic, and uniform coating. 


Eczema of the Hands and the Feet. [Eczema Manuum. 

Eczema Pedum.] 

No more striking illustration of the significance of the etiology of 
eczema can be adduced than that to be discovered in the hands. By 
these organs man toils to earn his bread, and the eczema they display 
is their protest against the rude contacts which are thus necessitated. 
Unfortunately, in too many patients the imperative necessity of bread¬ 
winning forbids consent to the best method of relief, viz., temporary 
disuse of these organs. The feet may or not be similarly attacked, 
and for similar reasons. All forms of eczema are here seen—erythe¬ 
matous, vesicular, papular, pustular, and squamous—involving the 
entire surface, or being limited to the wrists, ankles, interdigital 
spaces, palmar or plantar surfaces, or one or more digits on either 
hand or foot. The motions of the part are so free that fissures are 
common and often are exceedingly painful. The itching may be severe, 
and parts of one haud or of a foot may be extensively rubbed, torn, 
or abraded by the other. Vesicles are more frequently encountered 

23 


354 


DISEASES OF THE SKIN. 


upon the more delicate portions of the skin, as over the dorsum and 
interdigital spaces, while in the denser palm and sole they are repre¬ 
sented by subepidermic points from which by puncture a clear serous 
or a cloudy fluid may be evacuated. Usually, however, in the regions 
last named, there is a dry, dead whitish or hyperemic, uniformly 
indurated and thickened integument, which may be fissured or which 
may produce such a tense inelasticity of the surface that the fingers 
are semi-flexed into the palm, or, much more rarely, the toes are ren¬ 
dered considerably less extensible. 

Circumscribed patches of eczema, with fairly defined outline, reddish 
in color beneath crust or scale, subacute in course, and accompanied 
by paroxysmal itching, are of common occurrence on the dorsum, and 
also on the palm or the sole. In the latter situation they may be trav¬ 
ersed by one or more painful fissures, the same being true of the fingers 
and the toes. Upon the back of the hand these circumscribed patches 
are apt to assume an indolent course, improving temporarily under 
appropriate treatment, and becoming aggravated by every exposure 
to the causes by which they were first induced. 

Etiology. The long list of etiological factors which may here be 
efficient can scarcely be enumerated. Several have already been con¬ 
sidered in discussing the causes of eczema in general. The influence 
of all articles handled in the trades, occupations, and professions, as 
well as the action of toxicants and dyes, must be remembered. Thus, 
printers, bakers, and masons suffer in the hands, and the wearers of 
dyed stockings and coarse, ill-fitting shoes and boots, suffer in the 
feet. Because needle-women are often overworked, nervous, pale, and 
thin, their digital eczema, really due to the implements and stuffs they 
handle, has erroneously been attributed to their general condition. 

Diagnosis. In the matter of diagnosis, it should be remembered that 
an eczema of the hands may be induced by the Rhus toxicodendron , the 
disease being then liable to be transferred by contact from the hands to 
the face and to the genital or the mammary region. Scabies of the same 
region in America is rarer than eczema manuum. In scabies the vesi¬ 
cles are firmer, more often unruptured, are fewer, are more isolated, 
and more intermingled with crusts, pustules, and even with bullae, 
which latter are rare in eczema. The discovery of the parasite or its 
burrows and a history of contagion will aid in removing doubt. 
Abundance of pustular lesions in young subjects is, however, accord¬ 
ing to Hebra, most commonly produced by the acarus. 

The characteristic burrow made by this parasite, an irregularly 
curved, thread-like, beaded, or dotted line, about one-quarter of an 
inch in length, either running at a tangent from an unruptured vesicle 
or across its summit, is proof of scabies only second in value to the 
discovery of the parasites themselves. The occurrence of the eruption 
elsewhere on the body is also to be expected in the last-named disease, 
with respect to which it should be remembered that the burrow may not 
be visible, and that it may be wanting when the parasites are present. 
Psoriasis of the palms and soles is almost always accompanied by 
the presence in other parts of the body of patches, whose typical char¬ 
acters should throw light on the local disorder. They are dry, non- 


INFLAMMA TIONS. 


355 


discharging lesions, very rarely fissured as is the eczema of the hands, 
have a distinct contour, and are covered with more abundant and more 
lustrous scales. The scaling syphilodermata of the palms and soles 
occur early and late in the disease, and usually after a distinct history 
of infection. The lesions in syphilis are usually isolated, firm, deep 
infiltrations, circular in outline, with very sharp definition, and they 
may be covered by dry, adherent, dirty-white scales, beneath which 
the brown and red hue of the persistent lesion can be discovered. 
Superficial or deep circular excavations of tissue, single or multiple, 
with punched or ragged edges, are visible. The eruption is rarely, 
like eczema, accompanied by itching, or by discharge, but painful 
fissures may form. It occasionally affects the dorsum of the hand 
or the foot, favorite sites of eczema manuum, but almost invariably 
it has in such cases swept thither from the palm or from the sole. 

In both syphilis and eczema of the hand the right organ in right- 
handed toilers is invariably most involved, even where there is apparent 
symmetry of distribution of lesions. 

The treatment demands, first, rest for the organs, and a simultaneous 
discontinuance of the exciting cause. In the trades, the result of the 
latter can usually be demonstrated by the patient, who notices the 
difference between the condition of the skin on Monday morning after 
a Sunday’s rest, and that which was distressing on the preceding Sat¬ 
urday night. When practicable, protection during labor must be 
secured by the use of gloves, neatly applied finger-cots, rubber-stalls, 
or bandages, retaining a dressing to the part of the hand or the foot 
that is the seat of the disease. For circumscribed, non-discharging 
patches on the dorsum of the hand or the foot the dressing described 
in connection with eczema of the extremities may be applied. When 
the nature of the labor performed is such as to render it impossible to 
secure protection of the hands or fingers in this way, something may 
be accomplished in a few cases by directing that the hand be frequently 
dipped in a protective solution, or powdered during the hours of labor. 
Thus, printers may dust their fingers with lycopodium, and individuals 
compelled to retain their hands in irritating solutions can anoint these 
organs occasionally with an oily or fatty substance. Generally it may 
be said that an eczema of the hands is too frequently washed, and the 
ill-effects of this practice are made evident not only in laundresses, but 
also in mothers who personally attend to the dressing of young infants. 
The local applications made to each case may be those described above 
as suitable to each stage of the disease. When extensively involved, 
the hand should carefully be dressed, each finger being separately 
wrapped in soft linen rags smeared with camphorated or carbolized 
(pure or diluted) linimentum calcis in acute cases; or, later, with the 
Lassar paste, or bismuth, zinc, or mercurial ointment. Tarry com¬ 
pounds are here very useful, and caustics more than ever needful 
when there are fissures. The fissures may often with advantage be 
painted with compound tincture of benzoin. Protective flexile col¬ 
lodion plays an admirable part about the finger-nails where irritable 
seams and fissures form with overhanging fringes of a torn and ragged 
epidermis, bordered with red. In all painful eczemas of this region 


356 


DISEASES OF THE SKIN. 


the immersion, particularly at night, of the entire hand or the foot in 
hot borated water may be practised, followed by careful drying and 
anointing with a salve or an oleaginous semifluid. This salve should 
be spread thickly upon pieces of muslin, wrapped neatly about each 
finger separately, and other affected parts, and the whole be covered 
with waxed paper. The Lister protective gauze, or a pair of rather 
large undyed gloves which can be readily drawn over the whole, may 
be subsituted for the waxed paper. 

When the epidermis of the palm is greatly thickened it should be 
shampooed at night with green soap, pure or in spirit, by the aid of 
hot water, followed by a salve containing either white precipitate, 10 
to 20 grains to the ounce (0.66-1.33 to 32.), or Wilkinson tar-salve. 
For intractable cases caustic potash, in the strength of 20 to 30 per 
cent, solutions, can be mopped well into the thickened palm and be 
followed by a salve application. Van Harlingen suggests : 


R.—Hydrarg ammoniat., 9j ; 1 33 

Adipis, 3ss; 2 

Sevi benzoinat., ^vij; 10 

01 amygd. dulc., TTLx; 66 

Vaselin., ad ^vj; 241 M. 


For the fingers and hands Unna’s mull-plasters, but only if freshly 
imported, fill very perfectly every requirement. These plasters may 
be cut into strips, and be applied with neatness to every digit. Zinc 
oxid, tar, and ichthyol mulls are all available for this purpose. 


Eczema as it Affects the Nails. [Eczema Unguium.] 

There is nothing characteristic of eczema in its effects upon the nails. 
These horuy plates participate in the diseases which affect their matrices, 
and thus exhibit nutritional changes. There is, therefore, no eczema 
of the nail proper, but only an eczema of the digit by which the nail 
is affected. In well-marked cases, one, several, or all the nails of 
either hands or feet may lose their polish, or may become rough, punc¬ 
tate, furrowed laterally, and clubbed, or may present an appearance 
suggestive of worm-eaten surfaces. They lose their uniformly smooth 
attachment beneath, and become tilted on their beds, with marked 
friability of their tissue. An eczematous condition of the skin at the 
nail-margin may be detected, where the usual redness, infiltration, and 
scaling, with a sensation of itching, point to the nature of trouble. 
Rarely the nails are shed. The most misshapen will be succeeded by 
smooth and natural growths of nail-substance, if the disease of the 
matrix be completely relieved. The treatment, therefore, is the treat¬ 
ment of the cutaneous disease. Care must be taken to exclude ring¬ 
worm of the nails, which end can be reached by microscopically 
examining the scales scraped from the nail surface. 

Zinc-oxid, white-precipitate, and tar salves will be found most effec¬ 
tive for the larger number of cases. Often the organs may be with 
advantage protected during the daytime by the combination of gelatin 


INFLAMMATIONS. 357 

and glycerin described in the management of eczema of the extremities, 
or by rubber cots. 


Eczema of the Tropics (Prickly Heat). [Eczema Solare ; 

Lichen Tropicus, etc ] 

Under these titles has been described a number of disorders, some 
of which are more closely related to the forms of sudamen described 
in connection with the functional derangements of the sweat-apparatus, 
others of which are instances of papular eczema, associated or not with 
profuse sweating under the influence of high temperatures (solar heat, 
tropical climates, hard labor in the heated air of engine-rooms, etc.). 
This disease is aggravated by all external and internal sources of irri¬ 
tation, including alcoholic beverages, opiates, flannel and chemically 
dyed garments worn next the skin, undue exertion in a heated medium, 
fatigue, and obesity. 

Etiology. The disease is more common in those subjected to rapid 
and intense fluctuations in the temperature of the atmosphere than in 
those long accustomed to a relatively hot climate. It is thus exceed¬ 
ingly common in the northern and central parts of the United States, 
where the absence of a regulating Gulf Stream ushers the inhabitants 
suddenly from the rigors of a severe winter to the prostrating heats of 
summer. It attacks alike individuals of both sexes and all ages, being 
often particularly severe in the obese and in infants, whose delicate 
skins, no less than their bowels, resent sudden and severe thermal 
changes. It, moreover, equally affects the vigorous and the debilitated. 

The disease is characterized by the occurrence of pin-point- to pin¬ 
head-sized vesicles, bright-red papules, vesico-papules, or the two as 
coincident and commingled lesions. The lesions are exceedingly num¬ 
erous, and may in severe cases cover almost the entire so-called u non- 
hairy ” surface of the body, though they may be much more limited 
in their diffusion. They are usually acuminate and discrete, though 
often very thickly set together. They are rapid of' occurrence, but 
in consequence of persistence of the cause may be slow to disappear 
or may repeatedly recur. Whether vesicles be or be not present, the 
affected region is the seat of characteristic sensations of tingling, prick¬ 
ing, and burning; its lesions, even though generalized, may be most 
vivid or most distressing about the trunk, the axillae, the head, the 
neck, or the extremities. The attack may last for but a few days, or be 
severe for a week or more. It is unquestionably seen in the severest 
grade among fleshy Europeans and in Americans emigrating to tropical 
climates who are habitually ingesting alcoholic beverages in excess. 

Treatment. The local treatment of prickly heat is, in brief, that 
of the corresponding stage of eczema. Unguents are generally to be 
avoided, as the skin rarely tolerates them, and the same may be said 
of plasters and very cold baths. Baths or lotions (tepid, warm, to 
moderately cool, as the feelings of the patient may decide to be most 
grateful), medicated with alkalies, bran, gelatin, or starch, will be 
found useful. After each application the skin is to be dried by gently 


358 


DISEASES OF THE SKIN. 


pressing dry towels over the surface, not by rubbing, and is then to 
be thoroughly protected by a free use of one of the dusting-powders, 
particularly boric acid and talc. When large tracts of the skin are 
involved, and general baths have been ordered, a package of “ corn¬ 
starch farina ” will often be found well suited for such topical employ¬ 
ment. 

Lotions may also be employed, composed of lead, or of lead and 
opium, or black wash, or alcoholic and ethereal solutions containing 
camphor and glycerin in the proportions given when considering the 
subject of acute eczema. Modifications of oleated lime-water are 
serviceable in severe cases, as, for example : 


B. —01. lini, 

Paraffin., \ 

Sapon. Castil., J 

f E ; 

64 

aa |ij; 

64 

01. bergamii, 

q. s.; 

q. s.| 

*Aq. calcis, 

Sig.—For external use. 

ad Oj; 

500, 


This preparation makes a demulcent creamy solution which often 
proves exceedingly grateful to the skin ; to it may be added zinc oxid 
or dilute hydrocyanic acid, as may be required. 

The general treatment of the patient is a matter of importance. The 
cause must be removed if possible. Withdrawal from the light, heat, 
and labor of the day, the use of unstimulating food and drink, unirritat¬ 
ing apparel, and rest, are of great importance. Saline and acidulated 
beverages are usually acceptable to the palate, and useful if not drunk 
too cold. The chief value of Apollinaris water, lemonade, Vichy, 
and Kissingen lies not in their action as medicaments, but as supplying 
the water demanded by the cutaneous loss through evaporation. 

Prognosis . The disorder may be trivial or be severe, and may last 
but for a few hours, or for several months. It is usually relieved 
without difficulty, often by domestic measures alone. It is most annoy¬ 
ing and severe when complicated by an exudative process in other 
parts of the skin than the sweat-ducts and their immediate vicinage. 


Universal Eczema. 

In these cases patients should be treated in bed. The diet, which is 
of great importance, should be of unstimulating quality ; while it is not 
to be forgotten that in a disease involving the entire surface of the body 
the strength is sooner or later apt to be exhausted, and a supporting 
dietary, even ferruginous tonics, are often required. 

Treatment. The local treatment is by alkaline and bran baths, fol¬ 
lowed by lime-water and oil-lotions; or preferably by dusting the 
surface with borated starch and talcum, one part of the former to two or 
three of the latter. In treating universal eczema the entire surface does 
not usually require the same topical agents. Often there should be cold- 
cream salve, freshly made, for the eyelids; a dusting-powder for the 
non-discharging or scaling surfaces; a salve or an oleated lotion for 


INFLAMMA TIONS. 


359 


discharging surfaces of the integument; and special dressings for the 
extremities, the ears, the hands, etc. 


Parasitic Varieties of Eczema. 

The parasitic eczemas all require treatment for the destruction of 
the parasite productive of each. Thus, scabies is practically an 
eczematoid disease due to the presence of acarus; and eczema margi¬ 
natum is to be relieved by treatment proper for ringworm of the non- 
hairy parts. Unna discovered in cultures from seborrho'ic eczema fifty 
different mucors, twenty varying kinds of penicillium, five aspergilli 
(forms belonging to groups of o'idium and saccharomyces), and cocci 
and bacilli, all of which may perhaps exist without injurious effects 
upon the healthy tissues, but some of which may be capable of inducing 
the disorder calling for treatment. 

For further details respecting parasitic forms of eczema consult the 
chapter devoted to Dermatitis (Eczema) Seborrho'ica 


DERMATITIS SEBORRHOICA : ECZEMA SEBORRHOICUM. 

Duhring was the first observer to show that a type of inflammation 
of the skin, to which he gave the name seborrhea corporis, was closely 
allied to, and usually consecutive to, seborrhea capitis. 

Later, Unna 1 advanced the theory that a single morbid process, to 
which he gave the name eczema seborrho'icum, is responsible for a 
number of varied clinical manifestations which had previously been 
considered to be separate disorders. Under this title he includes 
seborrhea sicca (or pityriasis) of the scalp, face, and body, some chronic 
circumscribed forms of eczema, and many cases which most observers 
still believe are forms of psoriasis. 

Though Unna gives to eczema seborrho’icum a wider range than is 
accepted by the majority of dermatologists, there is little doubt that most 
of the phenomena he describes under this title are intimately related, 
etiologically and pathologically. In America Elliott has furnished an 
excellent presentation of the subject . 2 In preparing the following de¬ 
scription the writings of both these observers have been freely consulted 
and their views in the main accepted. The term dermatitis seborrho'ica, 
given by Crocker to one form of the disease and applied by Elliott 
to all its manifestations, should certainly be accepted if the condition 
is to be considered a distinct disease, and not a form merely of eczema. 
While it is true of diseases of the skin, as of other organs of the body, 
that they do not always present themselves in the severely classical 
limits of scientific analysis, and are often commingled in confusing 
relations, it is of enormous importance to the student, in order to 
insure against remediless confusion, that these scientific groups be clearly 

1 Monatshefte f. praktische Dermatologie, 1887; and The Histopathology of the Diseases of the 
Skin, 1894. 

2 Morrow’s System, vol. iii. p. 273. 


360 


DISEASES OF THE SKIN. 


and rigidly separated in the mind. Such terms, therefore, as “ eczema 
seborrho'icum,” “ lichen psoriasis,” and “ syphilitic eczema’’ are in 
general to be avoided. 

Symptoms. Dermatitis seborrheica almost invariably begins on the 
scalp and often remains limited to this region, though as frequently 
it extends to the ears, temples, forehead, neck, and other parts adja¬ 
cent. The disease is not uncommon on other parts of the body where 
the sebaceous glands are large and abundant, as in the sternal, inter¬ 
scapular, inguino-scrotal, axillary, and umbilical regions. It may 
appear, however, on any part of the body, and in rare instances is 
even universal. The disease is extremely variable in its course and 
mode of extension. It may remain confined to the scalp for years and 
then extend to adjacent surfaces, or appear on portions of the body 
distant from the scalp, leaving the intervening surfaces unaffected. 
Such spreading of the disease may be very rapid, or so slow as to be 
almost inappreciable, while the lesions may be numerous, extensive, 
and acute in type, or few, scattered, and indolent in character. 

The affection varies considerably in appearance in its different phases 
and especially in different regions. In the scaly form, which is the 
most common, there may be simply a scanty or abundant formation of 
fine branny scales with apparently little other change from the normal, 
though the skin may be slightly reddened, and often has the peculiar 
yellowish color which Unna claims is characteristic of the disease. 
The scales may be quite large and abundant, and heaped up in dry, 
adherent masses, simulating those sometimes seen in psoriasis, but in 
such cases the scales are usually somewhat fatty. Frequently there is 
a coexisting seborrhea oleosa, with the formation of yellowish to brown¬ 
ish, soft, greasy, and non-adherent masses, suggesting crusts rather 
than scales, under which the skin is more or less reddened and the 
mouths of the follicles patulous. 

The disease often appears in the form of oval or rounded macules 
and patches, or as small scale-capped papules which may remain dis¬ 
crete, or may coalesce to form slightly elevated plaques. The macules, 
papules, and plaques are sharply outlined, and patches that are spread¬ 
ing peripherally frequently present a circinate border with a fading 
yellowish centre. By the coalescence of several such areas, polycyclic, 
gyrate bands may be produced. The color of the lesions is reddish or 
pinkish, modified by the yellow tinge, which is nearly always present 
in greater or less degree. Scaling and crusting in varying degrees are 
usually present as in the more diffuse forms described above. The 
lesions may occasionally be moist over all or parts of their surfaces, 
but the characteristic vesicles and pustules of eczema are absent and 
the discharge when present is usually distinctly greasy. Unna admits, 
however, that a transformation to the ordinary forms of moist eczema 
may occur in which the characters, both clinical and histological, of 
the original eczema seborrho'icum are lost. Of the varied manifesta¬ 
tions of the disease the scaling forms are the most common, but in a 
given case the type may change gradually or rapidly, and multiformity 
of lesions is not uuusual. Itching is usually slight and may be absent. 

On the scalp the onset of the disorder is particularly insidious and 


INFLAMMA TIONS. 


361 


often unnoticed until attention is attracted to it by a thinning of the 
hair, moderate or really annoying pruritus, and a scanty or abundant 
formation of scales over more or less of the scalp. In the early and 
mild forms the condition is practically that described under seborrhea 
sicca. The vertex is the usual site of the affection, but the entire 
scalp may be involved. The scales may appear in any of the forms 
described above, but are usually fine, dry, grayish, and slightly greasy. 
The lowest layers of the scales are usually quite firmly attached to 
the underlying surface which is commonly dry, lustreless, and pale, 
though it may be slightly hyperemic. After the condition has existed 
for a time some alopecia is noticed, while the hairs of the affected 
regions are dry and lustreless. The condition may persist for months 
or years with but slight change. In more severe forms the heavier 
masses of scales and crusts described above may form upon distinctly 
reddened or moist patches. Seborrhea oleosa may complicate the pro¬ 
cess with its characteristic greasy crusts and oily condition of scalp and 
hair. In infants and occasionally in adults an acute dermatitis may 
supervene involving portions or all of the scalp and usually extending 
to the adjacent portions of the face. The conditions known as milk- 
crust (described under seborrhea) might well be considered a form of 
dermatitis seborrhoica. In adults circumscribed, oval or circinate, 
reddened, and scaling, moist or crusted patches may appear, chiefly 
about the temporal and parietal regions, often extending to the ears 
and portions of the face. Occasionally a sharply defined red band, 
more or less covered with scales or small crusts, may be seen at the 
margin of the hair, especially on the forehead and on the neck. Such 
bands closely resemble those of psoriasis, but usually have a more 
regular and even outline, much less infiltration and thickening of the 
skin, and lack the characteristic scales of psoriasis. 

The ears and the surfaces surrounding them are, after the scalp, 
more frequently involved than other parts of the body. Any of the 
above-described types of the disease may be seen in this region, the 
moist and crusting forms being quite common, especially back of the 
ears, where fissures frequently occur. The disorder not rarely affects 
to a very marked degree the lining of the external conduit of the ear, 
blocking it with crusts and interfering seriously with audition. 

The beard, moustache, eyebrows, and pubes may present symptoms 
differing but slightly from those in the scalp. The disorder may linger 
about the verge of the moustache or other parts of the beard, showing 
its grease and scales even at a distance from the line of hairs, with a 
well-defined reddened surface beneath them. The same occurs about 
the line of the eyebrows. Alopecia is very uncommon in any of the 
regions except the eyebrows. 

On the face the pityriasic forms are common on the nose and adjoin¬ 
ing portions of the cheeks, the eyebrows and the region between them, 
the eyelids and their margins, and may occur on any part of the face. 
Loss of hair from the eyebrows and eyelids is not unusual (see Sebor¬ 
rhea sicca). The more inflammatory, moist and crusting types are 
most frequent along the junction of the alse of the nose with the cheeks, 
but may involve the entire nose and other parts of the face. The 


362 


DISEASES OF THE SKIN. 


macular and papular types, above described, are most common on the 
cheeks. 

Upon the trunk is frequently found Unna’s “ flower-leaf ” or u peta- 
loid” type of the eruption which was first described by Duhring as 
seborrhea corporis , and which has been variously styled: seborrhea 
papulosa or lichenoides (Crocker), lichen circumscriptus (Willan), 
lichen annulatus et serpiginosus (Wilson), flannel rash, etc. Its favor¬ 
ite sites are the sternum and interscapular region, but may rarely be 
in more extensive areas on other parts of the trunk. In a well- 
marked case the lesions appear in the form of sharply outlined circles 
or segmeuts of circles which enlarge centrifugally, often coalescing 
to form patches with irregularly circinate outlines. The extreme 
borders, which represent the early stage of the lesions, are made 
up of very small red papules, usually covered with fine, whitish or 
yellowish, dry or fatty scales. As the border progresses, the centre 
undergoes involution, so that from without inward the patch may dis¬ 
play varying shades of red, brown, and yellow, while the whole surface 
is often the seat of a furfuraceous desquamation. Round or oval, some¬ 
what elevated, solid lesions are frequent, and may scale slightly or be 
covered by yellow, greasy crusts. In less perfectly developed cases 
and in those modified by friction of the clothing or frequent bathing, 
there may be simply yellowish, finely scaling patches with slightly 
reddened, more or less irregular borders. 

The eruption also occurs upon the trunk and extremities in the form 
of macules, papules, and reddened patches which by the coalescence 
of individual lesions may become quite large. These lesions may 
present any degree of scaling or crusting, though there is usually a nar¬ 
row uncovered reddened margin. The affected areas may be dry; and 
in form, distribution, and general appearance closely simulate psoriasis; 
or they may be somewhat moist and, as a result of irritation or of exces¬ 
sive exudation, may undergo a transformation to a condition indistin¬ 
guishable from that of eczema. In most cases the yellowish color of the 
lesions is conspicuous and is most marked when the eruption is fading. 

In the axilla and groin the eruption often begins as an erythema 
intertrigo, and owing to the influence of heat, moisture, and friction 
in these regions, secreting patches are quite common. From these 
points the disease often spreads to the adjoining surfaces, the advancing 
margin of the eruption always being sharply outlined and usually of 
circinate contour. 

The dorsal surface of the hands and fingers may be involved, and 
also the palms, where pea-sized and larger ill-defined scale covered 
macules are irregularly distributed over the surface. 

Etiology. In his first description of eczema seborrhoicum Unna 
claimed for it a parasitic origin. He has described three varieties of 
diplococci which he found in the lesions of this disease, beside several 
varieties of bacilli which were occasionally present. Of these he con¬ 
sidered a mulberry-shaped coccus, which he called the morococcus , of 
special importance, and produced with it, by the inoculation of pure 
cultures, typical vesicles of eczema. He also found Melassez’s flask¬ 
shaped bacillus in the scales. 


INFLAMMATIONS. 


363 


More recently Elliott 1 reports the bacteriological study by Dr. W. 
H. Merrill, of fifty cases of dermatitis seborrhoica. In all but two 
cases, on which a solution of resorcin had been freely used, bacteria 
of some kind were found. Merrill describes two varieties of diplo- 
cocci and a bacillus; all three of which were present in thirty-one 
cases, while one or two of them were found in most of ihe re¬ 
maining cases. Twelve inoculation-experiments were tried, of which 
seven were successful; from pure cultures of the cocci typical lesions 
of the disease were produced from which, in each case, the special 
coccus was recovered and cultivated. One of these cocci was decided 
to be chromogenic and the cause of the yellowish color characteristic 
of the disease. These experiments, though too few in number to be 
conclusive, would seem, when considered in connection with clinical 
evidence, to leave little doubt of the parasitic origin of the disease. 
Positive evidence of the transmission of the disease from one indi¬ 
vidual to another is difficult to get, though a history of probable con¬ 
tagion is sometimes obtained. 

Locally, heat, moisture, friction, and other forms of irritation may 
act as predisposing causes and favor the origin and spread of the disease. 
On the body it is often found in those who perspire freely and who 
wear woollen next the skin. On the scalp it is common in those who 
keep the head covered much of the time. Elliott reports that most of 
his cases occur in people who live for the most part indoors, and that 
the affection is unusual on those who live largely in the open air. His 
explanation of the greater prevalence of the disease in winter than in 
summer is that in the former season most people live more indoors, 
with poorer ventilation, and bathe less than in summer. 

The systemic conditions favoring the development of the disease are 
practically those named as predisposing causes of seborrhea. 

Pathology. Even in the mildest grades of the affection, correspond¬ 
ing to the condition known as pityriasis capitis, Elliott found u slight 
inflammatory infiltration about the papillary vessels and the ascending 
branches from the subpapillary plexus, and along the hair-follicles /’ 
while in the rete there were some vacuole-like formations and a few 
wandering cells. In severer grades the inflammatory infiltration ex¬ 
tended to the subpapillary plexus, and in higher grades to the entire 
cutis, which was then somewhat oedematous. In the rete vacuoles were 
numerous and their origin could be traced to a nuclear degeneration. 
Many wandering cells were present, also karyokinetic figures and areas 
of cell-degeneration. The horny layer was thickened and easily 
detached from the interfollicular spaces, but densely packed in the 
dilated openings and necks of the follicles. The sebaceous glands 
were apparently normal. The coil-glands in many instances were 
dilated and contained cast-off epithelial cells mixed with a granular 
debris, while mitosis and cell-degeneration were frequently seen. 
Elliott found no appearance that would warrant him in believing the 
coil-glands to be the source of the fatty hypersecretion. Unna, on 
the other hand, found fat in the coil-glands, and believes them to be 

1 A Preliminary Bacteriological Report on Eczema Seborrhoicum. New York Medical Journal, 
October 26,1895. 


364 


DISEASES OF THE SKIN. 


the source of most of the fatty secretion characteristic of the disease. 
He also describes an infiltration of small, free globules of fat through 
all parts of the cutis and rete, inside the lymph-spaces. Elliott found 
no evidences of such infiltration. 

Unna and Elliott agree in considering all stages of the process an 
inflammation of a catarrhal nature, the immediate cause of which is to 
be found in one or more specific micro-organisms. 

Diagnosis. From other forms, of dermatitis and from eczema, der¬ 
matitis seborrhoica may be distinguished by its origin on the scalp, 
its oily secretion and crusts, the yellowish color and sharp outline of 
its lesions, its tendency to spread peripherally in circinate outlines, and 
by its lack of marked subjective sensations. 

In some forms of the disease the diagnosis from psoriasis is difficult, 
but the location of the lesions on the flexor rather than on extensor 
surfaces, the oily character of the scales and crusts, the yellowish 
color, the greasy and scaly centre of circinate lesions undergoing 
involution, and the general course of the eruption, will usually suffice 
to distinguish the disease. 

Pityriasis maculata et circinata may present appearances identical 
with those of dermatitis seborrhoica of the trunk and extremities. 
The lesions in the former disease, however, do not appear on the scalp, 
usually have ill-defined, frayed-out borders, and the enlarging rings 
present a dry, fawn-colored centre which is free from greasy scales. 
The affection, moreover, runs an acute course, rarely lasting more than 
six or eight weeks. 

Treatment. Sulphur, resorcin, white-precipitate and other prepa¬ 
rations of mercury are remedies most useful in the treatment of all 
stages of the disease. For the earlier and dry forms, stronger and 
more stimulating preparations may be used, together with more frequent 
washings of the skin, than in the acute, moist forms, which must be 
treated more in accordance with the principles laid down for the treat¬ 
ment of the corresponding stages of eczema. For the scalp and other 
hairy portions of the body, lotions are usually better than ointments. 
The lotion recommended by Elliott, containing 3 to 20 per cent, of 
resorcin in equal parts of alcohol and water, is one of the best, and should 
be applied two or three times daily. For the dry forms of the disease 
a small amount of oil—preferably the oil of sweet almonds—to pre¬ 
vent the disagreeable drying effect of the lotion alone, may be added 
to this lotion. Instead of thus combining the oil with the liquid, a 
thin ointment containing resorcin or sulphur may be substituted for or 
applied after the lotion. After soap and water washings, which should 
be used often enough to prevent accumulation of scales and crusts, an 
oily or fatty application is always desirable. 

The most serviceable ointment in the majority of cases is one con¬ 
taining from 1 scruple to 2 drachms of sublimated or precipitated 
sulphur, 10 minims of balsam of Peru, and 1 ounce of vaselin. In¬ 
stead of sulphur, resorcin or white precipitate may be used. In some 
few chronic cases with much infiltration, the tars, pyrogallol, or chrys- 
arobin may succeed after the above-named preparations have failed. 
In acute forms, in which the symptoms are more those of an acute 


INFLAMMA TIONS. 


365 


eczema, pastes and ointments containing salicylic or boric acid are valu¬ 
able until the acute inflammatory condition has subsided, when prepa¬ 
rations containing sulphur or resorcin should be used. 

The disease is usually more amenable to treatment than eczema, 
though recurrences are common. 


DERMATITIS REPENS. 

Under this title Crocker describes an inflammatory disease of the 
skin (usually a consequence of injuries) spreading with a marginate 
border, and, as a rule, beginning over the upper extremities. Garden 
and Nepveu 1 have described cases which Crocker believes to be of 
the same class. 

The inflammation spreads from a traumatism, eventually producing 
a raw, reddish surface, denuded of epidermis and oozing at several 
points, the serous exudate also undermining the apparently sound 
cuticle. The disease spreads with uninterrupted steadiness, lasting for 
months, and in cases invading the larger part of an upper extremity. 

The extension is at times from coalescing reddish papules which 
discharge and leave thick, dirty-looking crusts. There is a definite 
margin to the diseased patch. In cases the disease begins with the 
formation of blisters. 

The disease has originated in cicatrices after amputation of a finger, 
from burns, from the irritation of the feet after walking barefoot on 
the sand, and from splinters under the nail. Crocker believes that the 
dermatitis results from peripheral nerve-irritation, and that there is 
a secondary parasitic involvement of the part. The disease seems to 
be a simple eczema marginatum, the traumatism being simply an 
initial factor of the process. The diagnosis from eczema depends 
chiefly upon the recognition of the limited outline of the disease, the 
entire denudation of the surface, the undermined edge, and the thinned, 
shining epidermis left after healing. The affection is to be treated as 
an eczema marginatum. 

Two cases of this disease were supposed to have originated in the 
minute traumatisms of the finger-nails occurring when farm laborers 
are engaged in husking corn by hand ; and one well-marked case fol¬ 
lowed the amputation of a finger. An excellent illustration of the 
disease is given in a colored lithograph accompanying the report of a 
case by Stowers. 2 

Success was obtained in one of the cases after employing locally a 
saturated solution of pyoktanin blue. In another case that had resisted 
continued and varied treatment, the lesions disappeared rapidly under 
application of a solution of hyposulphite of sodium. Crocker recom¬ 
mends a strong solution of potassic permanganate. 

1 British Medical Journal, December 11,1886. 

2 British Journal of Dermatology, vol. viii. No. 1, 1896. 


366 


DISEASES OF THE SKIN. 


PRURIGO. 

(Lat. prurire, to itch.) 

Prurigo is a chronic, exudative, cutaneous affection, commonly beginning in infancy 
or early childhood, and continuing through life, and is characterized by the 
occurrence on the extensor surfaces of the extremities and also on the trunk 
of minute, pale or reddish, millet-seed to hemp-seed-sized papules, with extensive 
infiltration and intolerable pruritus. 

Prurigo is one of those terms which in the past have led to consid¬ 
erable confusion in the nomenclature of cutaneous disease. In England, 
chiefly, it is applied with more or less looseness to disorders accompa¬ 
nied by the subjective sensation of itching, such as the prurigo mitis 
of Willan, and the disease well recognized under the title “ pruritus.” 
Prurigo in this loose sense represents a group of disorders due either 
to the invasion of animal or of vegetable parasites, to disorders of 
internal origin, to the ingestion of drugs, or to the other causes 
described under Pruritus. 

The title “ prurigo” in this work is strictly limited to the disease 
to which the name was originally given by Hebra, a disorder beginning 
in earliest life and continuing throughout its duration. It is the 
“ prurigo ferox” of some authors. Once observed only or chiefly in 
Austria, it has now, in consequence of extensive immigration, been 
occasionally seen in America. 

Symptoms. Mild and severe forms of the disease are distinguished 
under the terms Prurigo Mitis and Prurigo Ferox, or Agria. 
Incessant care, judicious treatment, climatic influences, and the com¬ 
forts of life commanded by wealth seem to determine the difference 
between the two. In both varieties of this affection, pin-head- to 
rape-seed-sized, firm, whitish, or reddish-white papules form, chiefly 
and primarily upon the extensor faces of the extremities, but from 
these localities gradually extending over the entire surface of the body. 
The itching they produce is of the severest type. 

The earliest symptoms are usually displayed in the latter portion of 
the first year of life, in the form of an urticarial rash, which persists 
and which is finally succeeded by typical papules. These papules are 
minute, often subepidermic, and rapidly become covered with blood¬ 
stained crusts in consequence of the induced scratching. Then ensues 
a long train of symptoms, including pustulation, fissures, excoriations, 
dense infiltrations, crusts formed of exuded serum and dried blood, 
oedema, diffuse dark-brown pigmentation of the skin-surface in large 
areas, and consequent adenopathy. Fully developed, the disease pre¬ 
sents in general the same physiognomy in different patients of different 
ages. The lower extremities always exhibit the severest manifestations 
of the disease, especially the thigh and leg as distinguished from the 
foot; though the trunk, the forehead, the cheeks, the neck, the arms, 
and the head may also be involved. The protected surfaces, as the 
axillae and the groins, except as regards adenopathy, are free from the 
disease. The general health of the patient manifestly suffers from the 


INF LAMM A TIONS. 


367 


insomnia and nervous agitation induced by the state of the integument. 
Emaciation, malnutrition, and cachexia are common sequels. The 
mental and moral tone of the patient thus harassed from early child¬ 
hood throughout an entire life is necessarily profoundly impaired. 
Insanity and suicide are reckoned among its remote consequences. 

The characteristic lesions first appear about the eighteenth or the nine¬ 
teenth month of life, the urticarial rash up to the second year produc¬ 
ing merely whitish plaques upon the skin, commingled with excoriations, 
and occasionally a marked degree of insomnia. The minute papules 
develop only later on the several regions of preference of the disease, 
at first appreciable only by the touch, later projecting from the surface 
and capped with a blood-scale from the scratching to which they have 
been subjected. Then are to be seen striated excoriations, bulkier 
crusts, pustules, dark, brownish-hued pigmentation, and a rubbing off 
of the hairs, such as is often to be appreciated over the brows of male 
patients with erythematous eczema of the face. CEdema, infiltration, 
and axillary and inguinal adenopathy supervene, so that by the end of 
the second year or at the beginning of the third the picture of prurigo 
is complete. At such an epoch the distinguishing marks of the disease 
are its selection of the extensor faces of the extremities and the pro¬ 
gression of symptoms with added severity from the arms to the legs. 
The natural furrows of the skin are all exaggerated. In exceptional 
cases the lesions are seen over the face and the dorsum of the feet. 
Eczematous attacks may complicate any case. As a rule, the patient, 
after maturity, and even old age, has been reached, presents practically 
the same morbid portrait as in earlier life. 

Prurigo mitis is precisely the same as the severer form of the disease 
with respect to the evolution of symptoms; the only difference to be 
observed is in their intensity. The papules are fewer, the recrudes¬ 
cence rarer, the itching less intense, and the amenability to treatment 
more pronounced. It is to be noted of all cases that they are influ¬ 
enced happily by the warm weather of the summer season, and by 
special attention to cleanliness and hygiene. 

Etiology. The disease occurs chiefly in Austria, few cases being 
recorded elsewhere. A patient, however, was exhibited at the Inter¬ 
national Medical Congress in London whom both Kaposi and Hebra 
recognized as affected with prurigo. Wigglesworth, Campbell, and 
others have reported cases in America. It is needful to remember 
that the term prurigo is here employed to designate the disease recog¬ 
nized by some authors as the “ true prurigo” of Hebra. It should 
never be confounded with pruritus, which, under various usages, may 
be the title of a mere symptom of a disease. Prurigo is more often 
encountered in the male sex, is never contagious, and is never induced 
by lice; but, according to Hebra and Kaposi, it may be grafted upon 
an hereditary predisposition. u Scrofula,” tuberculosis, malnutrition, 
u misery,” poverty, anemia, and filth are held to be severally favor¬ 
able to its development. Unquestionably the superior resources of the 
poorest classes in America will long protect them from the incursion of 
this inveterate malady. 

While typical prurigo ferox, as described by the Vienna school of 


368 


DISEASES OF THE SKIN. 


authors, is of such rarity that probably less than a dozen cases have 
been reported in America, the opinion is gaining ground that the same 
disease with milder manifestations (prurigo mitis) is much more com¬ 
mon here than at times has been believed. Patients with severe pru¬ 
rigo, treated by Hebra himself, have found their way to our clinic; 
they bore unmistakable symptoms of improvement after a residence in 
the United States, and almost every American expert has observed 
cases of milder type. 

Pathology. Kaposi practically admits that, striking as is the clin¬ 
ical portrait of this disease, its anatomical features are indistinguishable 
from severe forms of obstinate papular eczema. The microscope 
reveals merely a hypertrophy of the various elements of the epidermis 
and derma, deposits of pigment in the corium of the cutaneous mus¬ 
cular elements (erectores pilorum), and a consequent atrophy of the 
integument which has long been the seat of the disease. 

The hairs are thinly scattered, the root-sheaths loosened, and young 
cells are collected in abundance about the follicles. Schwimmer calls 
attention in this connection to the fact that many prurigo nodules are 
pierced with a hair. Auspitz believes that the disease is in fact a sen- 
sori-motor neurosis without essential lesion. Riehl 1 considers it as a 
chronic form of urticaria. Morison 2 regards the prurigo papule as 
formed by an infiltration beginning around the upper plexus of vessels 
in the corium, spreading thence to the papillary vessels, enlarging the 
papillae, and elevating the epidermis, which at an early stage becomes 
thickened above the vessels. Finally, the epidermis is penetrated, 
and within its strata there forms a vesicle containing serum, blood, and 
lymph-cells. The regions of infiltration about the hair-sheaths and 
sweat-ducts are regarded by Morison as a secondary and not as an 
essential part of the process. The color of the papule does not at first 
differ from that of the skin in the neighborhood, on account of the 
depth of the slight infiltration by which it is characterized, and for this 
same reason the papule can be distinguished by the touch before it 
becomes visible. 

Diagnosis. Remembering the extreme rarity of prurigo in America, 
it is to be distinguished chiefly from the various forms of papular 
eczema by the location of its lesions, by the course of the disease, by 
the age of the patient when it is first developed, by the great extent of 
the eruption, aud by the uniform type of its lesions. Iu prurigo, also, 
the fingers and the toes, the flexor aspects of the extremities, and the 
face are more or less spared. Under treatment eczema commonly 
yields at least in some portions of the skin, while prurigo does not. 

From pruritus, prurigo is readily diagnosticated by its general physi¬ 
ognomy and history, by its peculiar pigmentations and infiltrations, and 
by the special region chiefly affected. But both diseases may complicate 
prurigo, especially eczema, which is then ordinarily of artificial origin. 
In pediculosis corporis the parasites will usually be found upon the 
underclothing, while the lesions induced by the finger-nails never form 
closely packed papules. There is something highly characteristic in 


Archiv. f. J)erm. u. Syph., 1884. 


2 American Journal of the Medical Sciences, 1883. 


INFLAMMA TIONS. 


369 


the widely separated excoriations, the puncta from wounds inflicted by 
parasites, and the inflamed papules seen upon lice-bitten patients. 

In scabies the characteristic burrows of the parasites will usually be 
recognized, as also vesicular and pustular lesions. Urticaria can be 
mistaken for prurigo only in the earliest stage of the last-named disease. 

Treatment. In Vienna, sulphur, naphtol tar, green soap, baths, 
and frequent anointings with oily and fatty substances have occasionally 
served to ameliorate the severe symptoms of the disease. Mercury, 
carbolic acid, and boric acid, and diachylon and zinc ointments may 
also be employed upon different portions of the skin when indicated. 

The Wilkinson salve, representing a combination of tar, sulphur, 
and green soap, has proved of special value in many cases. Vlem- 
inckx’s solution ( q . v.), followed by hot bathing and corrosive-sublimate 
baths, 1 drachm of the sublimate (4.) to 30 gallons of water, has also 
been recommended. Internally arsenic has proved valueless, while 
carbolic acid has occasionally seemed beneficial. Cod-liver oil and the 
ferruginous tonics, with the bitters, will naturally be indicated in many 
patients suffering from malnutrition. A generous diet and a tonic 
regimen are essential to the management of most cases, patients afflicted 
with prurigo being usually found iu the most wretched hygienic con¬ 
ditions. 

Prognosis. The disease usually persists through life. The most 
favorable conditions are those where the patient is quite young and 
surrounded by circumstances which permit of untiring provision for 
all his needs. Many authors to-day pronounce the disease entirely 
curable in the early years of life. 


ACNE. 

(Gr. aKfirj, a point.) 

(Varus. Fr., Acne; Ger ., Hautfinne.) 

Statistical frequency in America, 7.34. 

Acne is an inflammatory disease of the sebaceous glands and perifollicular tissue, 
in which appear usually multiple and painful, firm, reddish, pin-head- to small- 
nut-sized nodules, which may result in suppuration and the formation of cicatrices. 

Symptoms. Acne is probably the cutaneous disease of most common 
occurrence, not excepting eczema. The latter affection occurs upon 
the face as often as upon other parts of the body, yet it is seen in per¬ 
sons upon the street with far less frequency than acne. * Eczema, 
however, is more distressing in its symptoms, and for that reason 
physicians are more often consulted for its relief, the disease thus 
acquiring a statistical preponderance. Acne is more tolerable, and, 
therefore, is more tolerated and less treated, especially among the poor. 

The disease chiefly occurs in the second and third decades of life, 
and is characterized in general by the occurrence of several and usually 
numerous, light red, dull crimson, or violaceous, pin-head- to small- 
nut-sized, circumscribed, ill-defined papules, nodules, tubercles, or non- 

24 


370 


DISEASES OF THE SKIN. 


projecting indurations of the skin, often commingled with the lesions 
of comedo and seborrhea sicca. The lesions are usually both slightly 
painful and tender, though upon this point there is a wide range of 
difference in different individuals, some patients tolerating with a sur¬ 
prising equanimity the most extensive invasions of the disease. The 
inflammatory process, which manifestly involves the sebaceous glands 
and periglandular tissues, may result in suppuration of one or of 
several adjacent follicles, as a consequence of which coalescence occurs 
and pea- to large-nut-sized, cutaneous and subcutaneous abscesses may 
form. In the large number of cases, however, the suppuration is 
limited to the area of the individual nodule, every feature of the entire 
process being displayed at the same moment in an affected individual. 
Under circumstances of special aggravation the disease may occur in 
acute forms, but it is commonly chronic, the acute phases being usually 
accidents of the general process. 

The disease chiefly occurs upon the face, but is seen also upon the 
neck, the back, and front of the chest, the genitals, and the extremities, 
the palms and soles alone being excepted. It is emphatically a disease 
of the early puberal epoch in both sexes, though occasionally is seen in 
middle and later life. In women the symptoms of the disease are 
usually most conspicuous at about the date of menstruation. It usu¬ 
ally lasts, when unrelieved, for years, during this period being subject 
to occasional exacerbations and remissions, but it commonly spontane¬ 
ously disappears as the full maturity of the body is attained. In 
severe cases it leaves indelible traces of its ravages, in the scars where 
suppuration has been extensive. It occurs also in very mild and 
severe grades. The various terms used in the description of the forms 
of the disease refer chiefly to its external features. 

Acne Artificialis. Various substances, either applied topically 
to the skin or ingested, are capable of producing acneiform lesions. 
Among them may be named tar, which may prove an irritant, whether 
employed externally or internally, and far more frequently the salts 
of iodin and bromin after ingestion. Tar-acne occurs both among 
workers in tar and those subject to the action of this substance for the 
relief of other cutaneous disease. Pin-head- to pea-sized, reddish- 
brown papules then form, at the apex of each of which is perceptible 
a minute blackish punctum, produced by the lodgement of a minute 
particle of the medicament in the orifice of a sebaceous follicle. Pus¬ 
tular and furuncular lesions are, however, also produced, and the same 
lesions occur in bromic and iodic acne. In the latter disease Adam¬ 
kiewicz and others have demonstrated the presence of the drug in the 
contents of the pustular lesions. Chrysarobin and a number of other 
medicinal substances are capable of exerting a like effect. 

Acne Atrophica and Acne Hypertrophica are terms employed 
to designate merely the lesion-relics of the disease. In acne atrophica 
there is complete atrophy of the gland-tissue, indicated by a minute 
sunken pit in the site of the former orifice. In acne hypertrophica 
there is, in consequence of the periglandular exudation, a thickening 


INFLAMMA TIONS. 371 

of the tissues about the acini, and a projection from the surface of 
persistent, pea-sized, indurated masses. 

Acne Cachecticorum or Scrofulosorum includes the symptoms 
encountered in the subjects of struma, scorbutus, marasmus, chloro- 
anemia, and tuberculosis. The lesions are more often developed on the 
trunk and the extremities than over the face, and are papulo-pustules, 
pin-head- to bean-sized, particularly indolent, and remarkable for their 
livid, purplish, lurid-red, or violaceous tint. The lesions are rarely 
indurated; more often they are seen as softish, pus- and blood-containing 
nodules, sluggish of career, and leaving minute cicatrices. Their feat¬ 
ures are due entirely to the general cachectic condition of the subjects 
in whom they occur. In an interesting paper Colcott Fox describes 
acne scrofulosorum as it occurs in infants. 1 

Acne Indurata. This type of the disease is less frequently 
observed than several of the other forms, but it is one which possesses 
certain distinct clinical features. Induration of the base of the acne 
papule may be noted in many cases of the simple form of the malady, 
but in others the glands seem generally to be distinguished as minute, 
very firm nodules, with no tendency to suppuration. The surface of 
the skin is often without marked change in color or of heat, the indi¬ 
vidual lesions exhibiting at times an unnaturally whitish aspect. They 
are felt when the finger is passed over the surface as dense, often 
conical projections, occasionally painful, and giving to the touch a 
sensation suggestive of the rough surface of a nutmeg-grater. Com¬ 
edones may often be discovered intermingled with the papules. The 
disease, when well marked, is apt to be extensive, occurring with 
characteristic expression among brunette, hairy male patients well 
advanced to the twenty-fifth year. It is often generalized over the 
forehead, cheeks and chin, and the back of the neck. 

Acne Papulosa. In acne papulosa the lesions are of a papular 
type, ranging in size from that of a millet-seed to that of a coffee-bean, 
whitish or reddish in color, and varying in the amount of firm indura¬ 
tion at the base. They are evidently due to hyperplasia of the peri¬ 
glandular tissue, and are often commingled with pustules, papulo-pus¬ 
tules, and comedones. At the apex of each papule is often distinguished 
the blackish point characteristic of acne punctata, or a minute, greasy, 
yellowish-white spot, which represents the non-pigmented extremity of 
an inspissated sebaceous plug. 

Acne Punctata. In this variety of acne the papule is formed 
about a comedo. When examined its apex is discovered exhibiting 
the characteristic blackish punctum of that lesion. 

Acne Pustulosa. This form is probably the most frequently 
observed of all the forms of the disease. The lesions are apt to be 


1 British Journal of Dermatology, November, 1895. 


372 


DISEASES OF THE SKIN. 


commingled with papules, comedones, and intermediate phases between 
the functional and exudative disorders of the glands. The pustules 
may be large or be small, containing merely a droplet of pure pus; or, 
when a true furunculosis ensues, a teaspoonful or more of pus may be 
mingled with blood and serum. This accumulation may speedily be 
evacuated artificially or accidentally, or be absorbed, or may remain 
for a long period of time in a species of cyst-like loculus, whence it 
can finally be expressed. In aggravated cases, two or more of these 
pustulo-furuncular depots may coalesce, forming nut-sized abscesses, 
or, not rarely, may become united by fistulous tracts, through which 
there is free communication of the fluid contents of two or more 
chambers. 

Acne Vulgaris is a term applied by several authors to the com¬ 
posite eruption which is common to many clinical cases. Here the 
various lesions described above (papules, pustules, comedones, etc.) 
are associated, usually on the face and over the shoulders, each in 
several degrees of development, often in conjunction with the scars 
left by a prior eruption. 

Acne Cornea is considered under the title of Psorospermosis. 

• Acne Disseminata is a name given by some authors to acne vul¬ 
garis, the common inflammatory type of the disease above described. 

Acne Keratosa is the AcnS cornee of French authors. In this 
affection cornified masses of sebum distend and project from the orifices 
of the sebaceous glands, particularly over the neck, but also over the 
face, the trunk, the elbows, the knees, and other portions of the body. 
There is some doubt whether this disease should not be classed with 
the ichthyoses, which it unquestionably resembles, or with the inflam¬ 
mations of the pilo-sebaceous crypt at the outer part—that part at least 
represented by its funnel-shaped opening. According to Leloir and 
Vidal, the disorder starts in a cornification of the epidermis of this 
region, precisely as in keratosis pilaris. By some French authors the 
condition is considered an early stage of keratosis (psorospermosis) 
follicularis. 

Keloid-Acne [Dermatitis capillaris papillitii] is a name which 
has been given to an inflammatory folliculitis and perifolliculitis, leav¬ 
ing deep infiltrations, usually, in the thick epidermis over the neck 
and the back of the trunk, though seen also upon the scalp and face. 
Wisps of thick, distorted, and evidently altered hairs project here and 
there from the affected surface. Reddish, and even vascularized nodes, 
tubercles, and bridges occur at irregular intervals, interspersed with 
rare acne-pustules and deep-seated, broad, even gigantic comedones. 
Sclerotic tissue, in brief, forms about the site of the acne-process quite 
like cicatricial keloid of the trunk and other situations. 

Acne Parasitica is a term which eventually will be extended to 
include many of the varieties of the disease described above. Some 


PLATE II 



Acne-keloid of the Back. 


[From a photograph ot_one ot the author’s patients,] 








INF LAMM A TIONS. 


373 


of the pustular lesions of acne result solely from dissemination of pus- 
cocci (originally imprisoned within the follicles) over the face by the 
finger-nails or other means. The good results obtained by an appro¬ 
priate therapy are often the fruit of a destruction of these micro¬ 
organisms. 

That some of these lesions are at times infected with the bacillus 
tuberculosis there can be no question. Not only have tubercle-bacilli 
been recognized in the pustules of some forms of acne, but singular 
degenerative and even ulcerative results have in rare cases been pro¬ 
duced, not solely due to the ordinary processes distinguishable in acne. 

Ulerythema Acneiforme is probably due in part to a tubercular 
infection, and is assigned in this work to another chapter. 

Contagious Acne (Diekerhoff and Gravitz) of horses (horse-pox) 
is compared by Kaposi to contagious impetigo rather than to human 
acne. It is characterized by an eruption of flattish, pea-sized and 
larger bullae, seated on an inflammatory base, and visible over the 
mane, the back, and the shoulders. 

Etiology. The causes of acne are in many cases exceedingly obscure 
and are probably numerous. It is common to describe the puberal 
change in both sexes as a frequent cause of the disease, but one should 
be slow to regard a physiological crisis as a disease-factor. It can 
merely be asserted with safety that, with the growth of the hair in both 
sexes at the period of puberty, there is an unusual activity of the 
sebum-producing function, and that this physiological is then the more 
readily perverted to a pathological activity. Needless to say that tens of 
thousands escape acne who survive puberty. The disease, however, is 
apt to appear first at this time of life, and, if not improperly treated, 
to disappear spontaneously when the full maturity of the body is 
attained. 

Inasmuch, also, as there is a close physiological connection between 
the genital function and organs, and the appendages of the skin, not 
only in man but also in the lower animals (antlers of the stag, plumage 
of birds, etc.), it seems reasonable to conclude, a priori, that the dis¬ 
turbances of the former may be reflected to the latter. Many facts 
support such reasoning. The effect of castration upon the male of 
many animals is displayed iu the appendages of the skin. In the 
same way perverted sexual instincts and habits, or a poorly regulated 
sexual hygiene, and uterine disease (which is indeed often traceable to 
the causes just named) are frequently associated with an acne. To the 
same category belong the disturbances of the gastro-intestinal tract, 
including constipation, dyspepsia, malnutrition from various causes, 
and the struma, tuberculosis, etc., which are responsible for acne 
cachecticorum. The medicinal agents capable of producing artificial 
acne, either by ingestion or after external application, have already 
been named. 

It should not be concluded, however, that any one of these condi¬ 
tions can be recognized as efficient in the majority of patients. Many 


374 


DISEASES OF THE SKIN. 


cases of acne occur in perfectly healthy young people of both sexes. 
A careful record of many cases of the disease, preserved upon blank 
forms in which is space for noting irregular performance of function, 
will exhibit no ailment common to the larger number in other organs. 
In these cases, therefore, it is proper to believe that the causes of the 
disease are entirely local, such as suffice merely to induce primarily 
alteration in the consistency, quantity, or chemical character of the 
sebaceous secietion, and, either as a cause or result of this alteration, 
there ensues an adenitis or a periadenitis and subsequently an infection 
with micro-organisms. 

Apart from local causes one should not forget that the use of 
cosmetics, the neglect of soap or the use of the cheaper and irritating 
varieties, excessive shaving on the part of the young man, friction 
from hatbands, “frizzes,” “bangs,” and dyed veils, too frequent 
fingering of the face (Wigglesworth), improper compression of the 
neck by tight collars, and a long list of other agencies may prove 
the immediate or the remote cause of the disease. It is believed that 
blondes of both sexes are the more frequent sufferers; but this obser¬ 
vation may have been suggested by the circumstance that in those of 
light complexion the symptoms of the disease are more conspicuous 
and disfiguring. It certainly seems that young brunettes, with thick 
skins and abundant growth of dark lanugo-hair, furnish the most 
obstinate cases. 

The distinct cause of acne is the mechanical irritation set up by the 
inspissation of the secreted contents of the gland. The next efficient 
cause is perversion of the glandular function, in consequence of which 
the secretion is changed in character. Lastly occurs infection with 
pus-cocci. 

Pathology. The microscopical appearances are briefly those of an 
inflammatory process with exudation involving the periglandular tissue 
of the sebaceous glands and hair-follicles, and that about the common 
excretory duct. There is the usual vascular engorgement, the multi¬ 
plication of protoplasm within and without the focus of the phlegmon, 
its metamorphosis into pus often mingled with blood, the destruction 
by suppuration of the sebaceous gland, and often the preservation of 
the hair-follicle, though the latter may also be involved in the destruc¬ 
tive process. According to Kaposi, there is no question that the 
first stage of the disease is always an anomalous performance of secre¬ 
tion or excretion in the sebaceous gland. Visible cicatrices rarely 
result, unless the destruction of the elements of the derma surpasses 
the original limits of the gland itself. Where suppuration does not 
occur there is generally relief of tension by extrusion of the inspis¬ 
sated gland-contents and resorption of the plastic or fluid exudate in 
the periphery. 

Diagnosis. The typical facies of acne vulgaris is readily recognized 
by the characteristic features already described. The reddish papules, 
pustules, comedones, and “ lumps” in the skin of the face of a young 
subject; the evident involvement of the sebaceous glands; the history 
of a chronic affection destitute of itching and, though possibly picked, 
quite unscratched; the occasional blood-crusts where lesions have been 


INF LA MM A TIONS. 


375 


squeezed or incised, are all significant facts. The pustular syphilide 
of the face is not only to be differentiated by its share in the history of 
an infectious disease, but also by the occurrence of characteristic crusts, 
its selection, by preference, of the regions about the nose and mouth, 
its evolution in groups, and its sequels in the form of superficial or 
deep ulcerations. Nevertheless (and this is a matter of prime impor¬ 
tance as regards diagnosis), simple acne is exceedingly common in syph¬ 
ilitic subjects. The iodid of potassium is so frequently administered 
for the relief of syphilis, and in so large a majority of cases induces 
its artificial acne, that the latter eruption often precedes the evolution 
of the macular syphilide, and also with surprising frequency masks 
the latter by a commingling of lesions. Simple acne is common also 
among those who are veterans of syphilis. Acne does certainly at 
times resemble variola, and cases of the former have actually been 
mistaken for variola. In most instances the absence of fever and a 
brief delay will soon put an end to any doubt. 

Treatment. Acne is an entirely remediable disease in every case 
properly managed from the first. Scars of ancient ravages of the 
affection are, it is true, indelible, but even these are smoothed down in 
the progress of time, so that they become yearly less conspicuous and 
disfiguring. 

The internal treatment of acne requires a careful and exhaustive study 
of the special requirements of each individual case. For most patients 
the question of diet is of the highest moment—that appropriate for 
the schoolboy and the schoolgirl, or the adolescent employed in factory 
or on the farm or in domestic labor. 

All well-fed subjects of acne are benefited in a high degree by reduc¬ 
ing the quantity of food ingested, especially in the item of meats. 
A milk-diet, or one composed largely of fish, fruits, and the lighter 
vegetables, will usually brighten up the most obstinate cases. Con¬ 
fectionery, highly spiced food, pastry, hot breads and cakes, sugars, 
fried articles, and potatoes are all excluded with great advantage. In 
most cases a great deal will be accomplished by cutting down the 
quantity of food eaten while regulating its quality. Alcohol is gener¬ 
ally to be prohibited; and it is idle to treat a severe case of acne in a 
young male subject who cannot for the time abandon the use of tobacco 
in every form. 

An important consideration, at the outset of treatment of a patient 
affected with acne, relates to any local internal medication previously 
employed. A very large proportion of all patients first claim the 
attention of the physician after ingesting drugs or making topical 
applications which have decidedly aggravated the original trouble. 
With or without the advice of others, such patients have often been 
engaged for months in swallowing the iodid of potassium, “red clover/’ 
and various nostrums calculated to “ drive out” the disease; or in rub¬ 
bing over the skin equally noxious proprietary substances. In every 
such instance the skilled physician should delay active treatment of 
the affection until the artificial acne has subsided, and the real condi¬ 
tion of affairs can clearly be recognized. The patient should be 
directed to discontinue his or her former practice, to bathe the affected 


376 


DISEASES OF THE SKIN. 


part in hot water at night, and after it is dried to apply any bland 
unguent. By these simple measures alone many cases can very greatly 
be improved, and some completely be relieved. The simplicity of such 
treatment should commend it to every reader of these pages. It is a 
good thing to know what not to do. 

The constitutional treatment of acne rests for its success upon the 
discovery of the cause of the disease. Many patients certainly require 
no internal medication, being entirely relieved by only local treatment. 
A thorough investigation of the habits of living—food, diet, bathing, 
occupation, and bodily functions—as these are described in the chapter 
devoted to General Diagnosis, is essential at the outset. 

Since dyspepsia and constipation are frequent causes of the disease, 
it is necessary to correct these disorders when present; also any con¬ 
ditions of acidity of the stomach, distention of the transverse colon, 
or’ marked anemia. 

Some modification of Startin’s acid-mixture, such as the following, 
will be found suitable for many cases: 


R.—Magnes. sulphat., ^ij; 64j 

Acid, sulphur, dil., f 3 ij ; 8 

Sodii chlorid., ; 4 

Ferri sulph., gr. v.; 33 

Cardamom, tinct. co., f gj; 4 

Aq. dest., adf t fviij; 265j M. 

Filtra. 


Sig.—A tablespoonful in a tumblerful of water before breakfast. 

Other cathartics, saline and alterative, will often prove serviceable. 

With the recognition of the several causes of acne, general and 
local, has come a day when few will trust to internal medication for 
its relief. Walter G. Smith, of Dublin, places sulphide of calcium, 
long highly esteemed in the management of acne, u side by side 
with the ludicrous specimens of therapeutic empiricism.” Arsenic, 
however, is highly recommended in acne papulosa, by both Du bring 
and Taylor. The internal employment of ergot in full doses for the 
relief of acne has been followed by excellent results. Cod-liver oil, iron, 
the mineral acids, and the bitters are needed in chlorosis and cachexia. 
Glycerin in teaspoonful to tablespoonful doses three times daily has 
proved valuable (Gubler). The mineral waters, Hathorn, Hunyadi 
Janos, often Racoczy or Kissiugen, a tumblerful before breakfast, are 
exceedingly valuable in cases of habitual intestinal torpor. When 
there is an acid form of dyspepsia the rhubarb and-soda mixture, or 
acetate of potassium in \ drachm doses (2.), will be serviceable. 

Temperate gratification of the sexual instinct in a happy marriage 
is conducive to good results; and this condition should generally be 
recommended as favorable for the future of young adults. Uterine 
disease, when this complication exists, should receive proper treatment; 
and this, far less by topical applications than by attention to the gen¬ 
eral health, as patients of this class are often chlorotic young women 
with menstrual derangements, leading sedentary lives, or overworked 
at the school-desk, the sewing-machine, or the shop-counter. 

In all cases, whether previously treated or not, which have been 


INFLAMMA TIONS. 


377 


purged of suspicion of an artificial element, the local treatment is of 
prime importance, and in the perfection with which its details are 
observed lies the key to success. It is not the selection of one of the 
several remedies of the many advocated for the relief of the disease, 
nor yet the successive substitution of one for another to meet any transi¬ 
tory indication in each case, that conduces to the happiest result; but 
it is rather the use of a single method of recognized value, and its 
skilful adaptation to the changing conditions of the disease. 

The most important of the methods of local treatment is without 
question the daily bathing of the entire surface of the body (with 
exception of the face and excluding the menstrual period in women) 
with water as cool as can be tolerated, by rapid sponging followed by 
brisk friction with coarse towels, or with the flesh-brush until the skin 
is glowing. Common salt may be added to this bath in the strength 
of one-quarter of a pound of common salt to each gallon of water. 
The results of this treatment are incomparably great in the majority 
of cases, especially where the patient has been accustomed to the hot 
or Turkish bath, which is detrimental to affections of this class. 

An effective method of local treatment is found in curetting the 
lesions as practised by Fox, of New York. A ring-curette is drawn 
over the affected surface so as to express the contents of the lesions and 
to stimulate others to activity. The subsequent bleeding is encouraged 
by sponging with hot water. All comedones are expressed, and the 
subsequent treatment is that suggested below. 

It is always necessary to evacuate the contents of pustules, to express 
from the summits of papules (where are the orifices‘of sebaceous ducts) 
all densely inspissated plugs of sebum, and to remove any comedones 
present, by the aid of the comedo-extractor. For the purpose of 
opening the superficial and smaller purulent collections the long needles 
used by gynecologists are decidedly preferable and for the larger and 
deeper furuncular lesions a bistoury with a delicate and very narrow 
blade. A slight degree of skill will here repay the operator. Piffard’s 
acne-lance is useful in this same connection, as also is Yolkmann’s 
spoon (as modified by Auspitz), which may be employed in removing 
pathological debris. By counter-depression with the fingers the whitish- 
yellow or blackish orifice of the duct may be detected, and at this point 
precisely the needle or the bistoury should be thrust sufficiently deep 
to insure removal of pent-up pathological accretions. Should blood 
flow in droplets from any of these slight wounds, it is rather to be 
encouraged than be repressed, as relieving the hyperemia and engorge¬ 
ment of the small periglandular phlegmon. In one or several sittings, 
all lesions requiring such interference should carefully be attacked, and 
immediately after each operation, preferably while the pus and blood 
still are oozing, the part is to be bathed for several minutes in water 
as hot as can be borne with comfort. For many reasons the hour 
before retiring is preferable, though not always practicable, in treating 
such cases, as then a bland ointment can thoroughly be applied and be 
permitted to remain until the following morning. 

When one or several of these operations have completely relieved 
the skin of its engorgement and retained inflammatory products a 


378 


DISEASES OF THE SKIN . 


systematic use, at night, of the spiritus saponis alkalinus ( q . v .) with 
hot water, should for a time be practised. Let it be noted, however, 
that many cases, which do not require the minor surgical operation 
described above, should from the first be treated in the following 
manner. As the face is the commonest seat of the disease, it may be, 
for the purpose of description, considered as the affected part. 

The patient is seated before a basin of water, which is as hot as can 
be tolerated with comfort, and, with a pad of white flannel or a soft 
sponge, he bathes the face until the skin is thoroughly moistened and 
softened by the heated water and steam. From ten minutes to half 
an hour may well be employed in this way, it being a fertile source of 
the improvement which follows. While the face is still wet all pus¬ 
tules which have formed are emptied, and a sufficient quantity of the 
spirit of green soap is poured over the flannel or the sponge, with which 
the face is then thoroughly scrubbed. Finally, the skin-surface is 
cleansed with a surplus of the water, carefully dried, and anointed 
with a sulphur-ointment. 

Some range may be observed in the employment of the two substances 
named. Thus, the spirit may be diluted with cologne- or with rose¬ 
water, one-half or more; or the soaps employed, in less imperative 
cases, may be the best toilet-soap, Sarg’s glycerin or sulphur soap. 
The ointment, too, may be compounded by adding from J drachm 
to 2 drachms (2.-8.) of sublimed sulphur to the ounce (32.) of cold- 
cream or of vaselin. In the morning the face is to be washed with 
cold water. 

This operation of steaming, soaping, and anointing is to be contin¬ 
ued, according to the severity of the case and the tolerance of the 
patient, nightly, or twice in a day, or on alternate nights, until the 
face is free from papules and other inflammatory lesions. After this 
vigorous treatment the face is usually unsightly, reddened, slightly 
tumid, and often moderately furfuraceous, but is free from acneiform 
lesions To the patient the skin feels tense, slightly painful, and as 
if made of leather. With the removal of the lesions the spirit, or other 
preparation of soap, may for a time be discontinued. The improvement 
which follows is marked and speedy, and usually is quite satisfactory 
to the patient. When this condition is reached, a wider latitude of 
treatment is permitted. 

Gradually the hot ablutions may be withdrawn, and the use of 
lotions and of ointments other than those containing sulphur may be 
advised. Sulphur, having the highest reputation in the disorders of 
the sebaceous glands, is a constituent of many of the lotions thus 
employed. 

Taylor 1 advises the following : 


-Sulphuris loti, 

3 iff; 

12 

Camphorse spts., 

f 3iij; 

12 

Sodse biborat , 

3fi; 

8 

Glycerin., 

f 3 v j; 

24 

Aq. fontan., 

ad f % iv ; 

128 


Sig.—Shake well and apply freely, leaving a thin film of powder over the 
face. 

1 American Clinical Lectures, New York, 1878, vol. iii. No. 10. 



INFLAMMATIONS. 379 

Various combinations of sulphur with alcohol will be found useful. 
Thus, Kaposi recommends a paste composed of: 


R. — Sulphur, prsecip., 

3 ijss ; 

10 



Spts. vin. rect., 


48 



Lavand. spts., 

f 3 ijss; 

10 



Glycerin., 


1 

3 

M. 

Sig.—To be spread over 

the face and retained during the 

night. 


Or, 





R. — Sulphur, flor., 

3 ijss; 

10 



Spts. sapon. virid., 

f 3 v ; 

20 



Lavand. tr., 

f^ij; 

64 



Peruv. bals., 

Tffxx; 

1 

3 


Camphor, spts., 

Iffxv; 

1 



Bergamot, ol., 

lv; 


33 

M. 

Sig. — To be applied over the face at night. 




Duhring recommends the following: 




R. — Sulphur, praecipit., 

; 

8 



Glycerin., 


8 



Alcohol is, 

fgj; 

32 



Aq. calcis, 

fjj; 

32 



Aq. ros., 

m; 

64 


M. 


Sig.—Shake the vial before using. 


Occasionally rumex ointment may be used with advantage as the 
basis of sulphur and other salves in acne. It is prepared according 
to the following formula: 


-Rum. crisp, rad., 


288 

Adipis, 

Ivj; 

192 

Cerae flav., 

Zi ; 

32 

Aq. pur., 

q. s. 



Wash and bruise the roots; boil for two hours; strain; evaporate to 4 ounces 
(128.) ; gradually add the wax and lard in a melted state; and stir until 
cool. 

The English hypochloride of sulphur, in ointments of the strength 
of those given above, and sulphuret of potassium, J to 1 scruple 
(0.66-1.33) to the ounce (32.) of lotion or of ointment, are effective, 
but objectionable on account of their odor. 

Various cosmetic ointments will be found useful in superseding those 
described above, as the case progresses. Among these ointments may 
be named oxid of zinc, subnitrate of bismuth, and freshly levigated 
calamin in the strength of J to 1 drachm (2.-4.) of one or more of 
these substances to the ounce (32.) of cold-cream salve, to which, as 
required, tincture of benzoin, glycerin, oil of roses, or bergamot, may 
be added in suitable proportion. 

For mild cases an excellent lotion is obtained by adding 1 drachm 
each (4.) of simple tincture of benzoin and glycerin to 4 ounces 
(128.) of distilled water, to which, where a more stimulating effect 
is desired, 1 ounce (32.) of cologne-water or of rectified spirit of wine 
may be added, or 1 scruple (1.33) of sulphuret of potassium. The 
following is the formula of the u Oriental Lotion,” according to 
Hebra: 






380 


DISEASES OF THE SKIN. 


-Hydrarg. chlor. corros., 

3j; 

4 

Aq. destill., 

Ovorum iij albumin., 


16 

Sued citri, 

3 hi; 

12 

Sacchari, 

ij; 

32 


The bichloride of mercury is very generally employed in the strength 
of from ^ to J grain (0.008-0.033) to the ounce (32.) of emulsion of 
bitter almonds as a lotion; and the protiodid, biniodid, and ammonio- 
chlorid of the metal are similarly applied in both lotions and unguents; 
the first two, in the strength of from 5 to 10 grains (0.33-0.66) to the 
ounce (32.); the last-named in the strength of from \ to 1 scruple 
(0.66-1.33). One should be careful not to make use of mercurials 
at the same time with a compound of sulphur, lest a chemical com¬ 
bination occur by reason of which sulphuret of mercury (sethiops 
mineral) is precipitated upon the skin and produces the appearance of 
comedo. Heitzmann highly recommends the solution of VJeminckx. 1 

Kaposi recommends in obstinate cases also mercurial plaster (applied 
on strips of linen), for which may be substituted iodated glycerin (five 
parts of each of pure iodin and the iodid of potassium to ten of gly¬ 
cerin), applied with a brush twice daily until from six to twelve appli¬ 
cations have been made. 

Van Harlingen employs 1 drachm each (4.) of sulphuret of po¬ 
tassium and sulphate of zinc to 4 ounces (128.) of rose-water. Fox 
applies J drachm (2.) of chrysarobin to the ounce (32.) of collodion. 
Taylor advises from 5 to 25 grains (0.33-1.6) of the iodid of zinc to 
the ounce (32.) of vaselin. Veiel employs the uncertain unguentum 
Rochardi: 

H-—Hydrarg. chlor. mit., ; 15 

Iodi puri , gr. vij ; 5 

Leni igne fusis adde 

Ungt. rosse aq., Jfij; 64 M. 

The paste recommended by Lassar is useful in some cases, that is, 
one part of beta-naplitol, two and a half parts each of vaselin and 
sapo viridis, and five parts of precipitated sulphur, spread over the 
skin for from fifteen to twenty minutes, and then wiped off, when the 
surface is dusted with French chalk. Ointments containing resorcin 
in the strength of 20 per cent, have been employed with advantage, 
as have also weak chrysarobin pastes, even though staining the face. 
In obstinate cases with few lesions the touching of the parts with pure 
carbolic acid or with salicylic acid, or acid nitrate of mercury, is 
useful, but such measures should be condemned for the majority of all 
patients at or near puberty. A fine needle connected with the negative 
pole of a galvanic battery may be employed to destroy single and 
indurated papules or papulo-pustules. 

For chronic and indolent cases the author has devised a modification 

1 The formula is : 

R.—Calcis, gss; 161 

Sulphur, sublim., gj ; 32 

Aq. dest., gx; 320 M. 

Coque ad gvj [192.] deinde flltra. 

Sig.—“ Vleminckx’s Solution.” 


INFLAMMATIONS. 381 

of the local treatment of acne by the aid of an instrument called the 
u massering-ball,” figured on page 92. 

This instrument consists of a stout, short handle, constructed of 
hard rubber, and connected by means of a slender steel neck with a 
ball set in a steel socket, the small sphere rotating within the cup of 
the socket, as in an ordinary ball-and-socket-joint. The free play of 
the ball is aided by its bearing upon a smaller ball set in the neck of 
the cup attached to the handle, which is fixed upon the socket at an 
angle sufficiently convenient for the operator, whose eye can thus better 
follow the play of the ball. 

The ball is constructed of hard rubber, and the area of its impact 
upon the skin at any moment is about that of the human thumb of 
average size similarly placed. When actually in use the ball travels 
with ease as well along the angles of the nares with the cheeks, the 
bridge and root of the nose, and the regions below the symphysis 
menti, as over the brow, the temples, the chin, and the cheeks. When 
necessary to cleanse the instrument the ball is detached by unscrewing; 
but the entire instrument may be boiled without damage to its useful¬ 
ness. 

When ready for treatment, the skin is first operated upon with dis¬ 
infected needle and comedo-extractor until all pustules and subepider- 
mic foci are emptied and conspicuous comedones are removed. After 
this the surface is rendered aseptic, either with one of the bichloride 
lotions or with a solution of formalin (40 per cent, of formic aldehyd) 
in the strength of from one-half of 1 per cent, to 2 per cent., accord¬ 
ing to the sensitiveness of the patient’s face. The massering-ball is 
then rotated freely over the surface, and deep pressure is made upon 
the affected region, with the result of bringing into view groups of 
previously inconspicuous comedones, which are in turn removed by the 
extractor or u presser.” Lastly, a massage of the surface is practised 
with the ball by the aid of a salicylated cocoanut-oil or by one of the 
sulphur unguents. 

The use of caustics in acne, though recommended by several authors, 
should in general be discountenanced as quite needless. In extreme 
induration of the lesions these may be rubbed with fine pumice-stone 
until the desired effect is produced. 

The powders employed in the milder forms of the affection are finely 
powdered sulphur, which may freely be dusted over the face, and those 
compounded, in various proportions, of starch, rice-flour, zinc oxid, 
and subcarbonate of bismuth. 

In America relief of acne in young male patients has been reported 
after the passage of the urethral sound, and, in both sexes, by hot- 
and cold-water injections of the vagina and urethra. 

Prognosis. The majority of all patients, even when untreated, event¬ 
ually recover. This natural involution of the disease is commonly 
attained in proportion as the body arrives at the maturity of its devel¬ 
opment, and accomplishes the sum of its important functions. Appro¬ 
priate treatment has, however, a remarkable and highly satisfactory 
influence in hastening the recovery of a large number of all patients. 
A small minority suffer from the unsightly complications and sequels 


382 


DISEASES OF THE SKIN . 


of the malady (cicatrices, keloid).* Exceedingly rebellious and even 
grave cases occur in the cachectic, those long and improperly treated, 
and those who, from necessity, are continuously exposed to influences 
unfavorable to the involution of the disorder, such as the subjects of 
epilepsy habitually ingesting the bromid of potassium, and the victims 
of syphilis requiring persistent use of the salts of iodin. 


Acne Rosacea. 

(Rosacea, Gutta Rosea. Fr., Acne Ros£e, Couperose ; 
Ger., Kupferrose, Kupferfinne.) 

Statistical frequency in America, 0.634. 

Acne rosacea is a chronic disease of the skin, chiefly of the face, often developed 
from or associated with the lesions of acne vulgaris, and is characterized by hyper- 
emic macules, patches of diffuse, dull-red erythema, telangiectases, inflammatory 
papules, or growths which may attain the size of that of a hen’s egg. 


Acne rosacea is most often displayed upon the nose, though it may 
also affect the cheeks, lips, and chin, and, rarely, the lateral regions 
of the neck. 

Symptoms. In the first grade there is a more or less diffuse and 
uniform, pinkish or dusky, but transitory redness, involving the ex¬ 
tremity of the nose and its contiguous parts, which coloration may 
extend from this region in a somewhat symmetrical figure over the 
cheeks and chin. The affected parts give rise to little or no subjective 
sensation. Under pressure of the finger the color disappears, the 
surface seems cool rather than hot, and the sebaceous glands are seen 
to be affected, as there is usually present either a seborrhea oleosa or 
an accumulation of yellowish-white, moderately inspissated sebum in 
the patulous orifices of the gland-ducts. When the redness has existed 
for some time minute blood-vessels can be seen ramifying over the 
erythematous surface. 

This disorder varies greatly with the general condition of the patient. 
At times it may scarcely be perceptible; again, after the stimulation 
produced by ingested food or by alcohol, after mental excitement, a 
paroxysm of coughing or laughing, or exposure to external irritation, 
the lesions may be even conspicuously deforming. This condition may 
endure for months or for years and then disappear, or may be succeeded 
by the second stage of the malady. 

In a second grade of the disease the redness becomes permanent, the 
capillaries dilate passively and appear as conspicuous, tortuous, straight, 
or anastomosing lines of reddish color about the nose, cheeks, chin, or 
forehead. 

Firm, purplish-red, painless, pin-head- to pea-sized nodules or pap¬ 
ules often rise from the erythematous surface, and they either display 
minute superficial and tortuous bloodvessels in the integument by 
which they are covered, or they project from a base about which such 
a telangiectasis has very irregularly been developed. The lesions are 


INFLAMMA TIONS. 


383 


apt to be intermingled with those of seborrhea oleosa or with acne 
vulgaris. When fully developed, this stage of the disease, though 
generally not productive of marked subjective sensation, produces an 
exceedingly conspicuous deformity. 

In the third stage (which is the most pronounced of the three) round¬ 
ish, sessile or pedunculated, lobulated or pendulous, firm, elastic, pink¬ 
ish-red, bluish, livid, or violaceous vegetations, traversed by finer or 
larger networks of blood-vessels, slowly develop about the affected part 
of the face, chiefly the nose. These vegetations may be single or be 
multiple, and in the latter case be isolated, or may be so closely united 
as to be scarcely distinguishable from one another. The acneiform 
lesions seen in the second grade of the disease may here also be appar¬ 
ent. In some cases there is a uniform, symmetrical, and elougated 
hypertrophy of all the soft parts of the nose, which may thus attain 
colossal proportions. It is these consequences of acne rosacea to which 
the term Rhinophyma has been applied. 

The course of the disease is very slow, and in by far the largest 
number of patients does not produce the exaggerated types of the 
second and third grades. The lesions may persist indefinitely as indo¬ 
lent symptoms of the malady in any one of its stages, or, in the case 
where there has been no new growth of vessels or of tubercles, may 
proceed to spontaneous involution. 

Etiology. The first and second grades of acne rosacea are common 
in women either at puberty or near the period of the menopause, in 
those who are pregnant, or those who suffer from utero-ovarian disease, 
frequent miscarriages, sterility, irregular performance of the menstrual 
function, or chlorosis. 

The disease is, however, seen in men of early and of late adult life. 
In both sexes it may occur in anemic and asthenic states; in both, also, 
its association with gastro-intestinal dyspepsia, constipation, and the 
immoderate use of strong tea and alcoholic drinks—beer, wine, and 
spirits—is a matter of common observation. According to Kaposi, 
the rosaceous nose of the wine-drinker is bright red; that of the beer- 
drinker, cyanotic or violet; that of the spirit-drinker, smooth, supple, 
fatty, and dark blue. The new growth of vessels and tubercles, with 
the rhinophyma of the advanced grade of the disease, is much com¬ 
moner in men than in women. In those whose faces are bronzed by 
exposure to the weather, the telangiectasic condition of the cheeks, 
rather than of the nose, is of frequent occurrence. Veteran sailors 
and soldiers are thus commonly affected. Persons who have frozen 
the nose or the cheeks on one or more occasions are similarly liable to 
the telangiectasic development. Any externally or internally operating 
cause which tends to retard the capillary circulation in the superficial 
portion of the skin is capable of inducing this result. Acne rosacea is 
at times conspicuously displayed in the mulatto. 

Pathology. In the first stage of acne rosacea there is merely passive 
hyperemia. The circulation of the blood in the superficial capillary 
plexus of minute vessels is retarded. Persistence of this condition for 
long periods of time results in paresis of the capillaries, with their 
consequent dilatation and hypertrophy, phenomena which characterize 


384 


DISEASES OF THE SKIN. 


the second stage, the sebaceous-gland disorder being a complication of 
the process. In the third stage the nodules are found to be composed 
of newly formed gelatinous elements, which are developed by organ¬ 
ization. According to Biesiadecki, there are also dilatation and hyper¬ 
trophy of the sebaceous glands, with dilatation, hypertrophy, and new 
growth of the superficial blood-vessels, and enlargement also of those 
trunks which ascend from the corium. 

The disease, however, is viewed differently by authors. By some its 
obvious connection with acne vulgaris is denied ; by others it is regarded 
as a seborrheal eczema. According to Besnier and Doyon, this disease 
represents: (a) superficial or deep, at first intermittent, then persistent, 
erythema; (6) sebaceous erythema (acne eczema),where there are unques¬ 
tioned steatorrhea and implication of the sebaceous glands with infiltra¬ 
tion and possibly exfoliation of the skin; (c) deep erythema with 
infiltration of the corium and plastic products about vesicles, follicles, 
and perifollicular tissue; (d) telangiectases, as described above; and 
(e) hypertrophies of the perifollicular derma. 

Diagnosis. Acne vulgaris is distinguished from acne rosacea by the 
absence of telangiectasis, and of the hypertrophic growths which char¬ 
acterize the developed lesions of acne rosacea. The tubercular syphilo- 
derm is recognizable by its tendency to ulceration and crusting and by 
the entire absence of telangiectasis. When the tubercles of syphilis 
are limited to the extremity of the nose (they are usually small in con¬ 
sequence of the influence of treatment) they often degenerate into char¬ 
acteristic, split-pea-sized, irregularly circular ulcerations, which are 
superficial in seat and frequently isolated. They leave similarly shaped 
and sized, depressed cicatrices at the tip and neighboring parts of the 
nose. As the process is much more rapid than in acne rosacea, these 
lesions, considered in connection with the absence of telangiectasis, fur¬ 
nish the most significant diagnostic symptoms of the disorder, for they 
often occur late in the history of syphilis, in individuals of middle life, 
and in varying shades of a dull-reddish color, circumstances particu¬ 
larly favorable for confusion regarding the identity of the two diseases. 

Zoster from involvement of the superior maxillary branch of the 
trigeminus, with diffused redness of one side of the nose and efflorescence 
of vesicles over its tip and ala, certainly strongly resembles acne rosacea 
with pustular lesions; but in zoster the painful character of the dis¬ 
order, its limitation to one side of the face, its transitory career, and 
its vesicular lesions are sufficiently characteristic. 

Lupus vulgaris, like syphilis, when occurring upon the nose, is to 
be recognized by the tendency of its papulo-tubercular lesions to ulcer¬ 
ation and crusting, by the absence of vascularity, and by the frequent 
presence of characteristic cicatrices. Unlike syphilis and acne rosacea, 
however, the history of lupus vulgaris usually extends from early child¬ 
hood. Lupus erythematosus is yet more readily differentiated, as it is 
not only unaccompanied by vascularization and ulceration, but is also 
characterized by scaling and symmetrical diffusion over much larger 
and defined areas, commonly extending from the bridge of the nose 
well on to the cheeks. 

Treatment. So far as there can be said to be any internal treatment 


INFLAMMA TIONS. 


385 


of acne rosacea, it is that employed in acne vulgaris; but in neither 
disease can such treatment be confidently described as effective in the 
dispersion of the local lesions. The treatment is that of the patient 
rather than of his disease. When alcohol has been in any degree pro¬ 
ductive of the local effects the use of spirits, wines, and beer is to be 
interdicted; but as regards confirmed rosacea this prohibition will 
prove to be of but little avail. The disease, when resulting from 
spirit-drinking, may persist after five years of total abstinence. 

The diet should be of the simple character proper for the patient 
with acne. All imbibition of hot liquids, even tea and coffee in excess, 
should be restricted as tending to congest the blood-vessels of the face. 
Everything having the same result in the habits, the occupation, or 
the clothing of the patient should be, as far as possible, deprived of 
influence, as, for example, wearing of tight collars and corsets, work¬ 
ing over hot fires, etc. 

In many patients who are the subjects of rosacea, as distinguished 
from the younger class of sufferers from acne vulgaris, there are evi¬ 
dences of lithemia, gout, and similar conditions, requiring even stringent 
rules in many particulars for the conduct of life. The use of sugar 
in many of these cases is to be restricted, meat should be permitted but 
once in the day, and other articles of food be selected with special care. 
Tobacco should never be allowed to male patients with well-marked 
symptoms, and the daily general bath described as of chief importance 
in the preceding chapter should here also be prescribed. 

All gastro-intestinal sources of mischief should also, when practi¬ 
cable, be set aside. In acne rosacea, even more than in acne simplex, 
dyspepsia and constipation are conspicuously effective factors. Here 
it is well-nigh imperative that there be a daily evacuation of the bowels. 

Internally, nux vomica, ergot and ergotin, ichthyol (ammonio-sul- 
phate), mineral acids and alkalies, and arsenic have all been recom¬ 
mended. Most of these drugs are absolutely valueless, aside from 
local treatment, in removing the symptoms of the disease. In gouty 
patients alkalies may serve to aid the patient, even though not of them¬ 
selves capable of relieving the rosacea; the same may be said of the 
use of iron in chloro-anemic women. 

The local treatment of the first grade of acne rosacea is substantially 
that of acne vulgaris. Stimulating lotions of green soap, alcohol, 
bichlorid of mercury, or sulphur in connection with ablutions by hot 
water, are of the highest value. In addition, the various ointments 
containing sulphur, mercuric oxid and iodids, and the continuous 
application of mercurial plaster should be employed if necessary. 

Van Harlingen reports rapid results from the application, several 
times in the day, of a lotion composed as follows: 


R.—Sulphuris prsecipit., 
Pulv. camphorse, 
Pulv. tragacanth., 
Aq. calcis, \ 

Aq. rosse, J 


3 j I 

gr. v; 
gr. x; 

aa f g j ; 


4 


33 

66 


32 


M. 


Fox, of New York, applies chrysarobin in traumaticin, J drachm 
(2.) to the ounce (32.); but this drug should certainly be reserved for 

25 



386 


DISEASES OF THE SKIN. 


intractable cases, as it may have severe results. Even, however, after 
the production of these severe effects, the benefits secured may be 
appreciable for months. 

When the diseased condition is that of the second grade the indica¬ 
tion is the destruction of the superficial capillaries, as well as the 
removal of the other indications present. Hardaway, of St. Louis, 
was early to suggest destroying the vessels by single or by multiple 
puncture of each with a fine cambric needle attached to the negative 
pole of a galvanic battery with six to ten elements in the circuit. 
This operation is better than the knife, which has repeatedly failed, 
and it may be regarded to-day as the established and effective method 
of removing all blemishes produced by dilated blood-vessels in this 
stage of rosacea. The method is simple, readily executed, requires no 
anesthetic, and is in many ways superior to all other methods, which 
now should be relegated to a second grade in the list as only to be 
proposed when, for any reason, electrolysis cannot be employed. Some 
vessels may completely be destroyed without the production of a 
cutaneous cicatrix which, in the course of a few months, can be recog¬ 
nized by the unaided eye. 

For details of this simple and elegant operation the reader is referred 
to the chapter on Hypertrichosis. For the cambric needle may often 
be substituted with advantage a fine jeweller’s brooch, annealed in the 
flame of a spirit-lamp. 

The vessels may be entered in one or several places, and the opera¬ 
tion be repeated until the last thread-like evidence of their existence 
has disappeared. The number of cells brought into the circuit must 
be somewhat graduated to the requirements of each case and to the 
locality of the skin operated upon. Fewer cells can be tolerated for 
the lip and alse than for the root of the nose, the cheeks, or the fore¬ 
head. Next in value after this operation may be named: 

Brushing the part cautiously with solutions of caustic potash, from 
10 to 30 grains (0.66-2.) to the ounce (32.) of water; and the local 
use of pure carbolic, chromic, pyrogallic, and glacial acetic acids, 
acetum cantharidis (Taylor), iodid of sulphur, or solution of per- 
nitrate of mercury. Before any of these drugs are employed, how¬ 
ever, an effort should be made to produce exfoliation, by spreading 
over the part a plaster made of green soap. Unna’s mercurial plaster- 
mull is similarly applied. Kaposi highly recommends the solution of 
iodated glycerin, employed by him in acne vulgaris (q. v.), which solu¬ 
tion is painted over the part from eight to twelve times daily for three 
or four successive days, and is immediately covered with gutta-percha 
paper. 

Multiple scarification of all new growths after the manner of attack¬ 
ing lupus-nodules, erasion with the dermal curette or with Braun’s 
spoon, and surgical ablation or decortication of tumors by ligature and 
knife, are also available. After any destructive attack upon the diseased 
portions of the skin the soothing lotions, fomentations, or ointments 
should regularly be applied. 

< Prognosis. A favorable prognosis can be given in cases where the 
disease is presented in its milder forms. In cases complicated by 


INFLAMMA TIONS. 


387 


marked telangiectasis and hypertrophy, the results of treatment are 
often in the highest degree encouraging. Notwithstanding the most 
energetic procedures, however, the vis-a-tergo of passive hyperemia, 
involving often the deeper and unassailed blood-vessels, may work 
its slow progress. For women the future is in general more promising 
than that of men. With the most unfavorable prognosis, however, it 
is to be remembered that, after all, the disease is one of deformity 
rather than of physical discomfort. 


Acne Varioliformis. 

(Acne Frontalis, Acne Rodens, Acne Necrotica, Miliaire 
ScROFULEUSE, ACNE ATROPHICA.) 

Acne varioliformis is characterized by the occurrence, over the brow, scalp, or other 
regions, of reddish-brown papulo-pustular lesions, the desiccation of which leaves 
behind a crust which covers a cicatricial depression. 

This disease is not to be confounded with that to which Bazin and 
other French writers once gave the name Acne varioliforme , viz., mol- 
luscum epitheliale (molluscum verrucosum, of Kaposi). 

Symptoms. The disease is characterized by the occurrence over the 
centre or the upper portion of the forehead, the temples, or margin 
and central portions of the scalp, of pea- to bean-sized, firm, reddish- 
brown papules, each of which becomes pustular at the apex, and which 
are commonly indolent and often grouped. The pus of these lesions 
desiccates in crusts which are flattish, closely adherent, and apparently 
depressed below the general level of the skin. On the fall of the crusts 
there is left a rather deeply tinted brownish-red cicatriform lesion, 
somewhat resembling the cicatrix of variola, from which the disease 
received its name. The scar much more closely resembles, however, 
the results of the involution of the pustulo-tubercular syphiloderm in 
groups. The subjective sensations are slight, at times there is itching. 
The disease tends to recur and is exceedingly chronic in course. 

In exceptional cases the disorder occurs in other regions than those 
named above; for example, over the dorsal and sternal aspects of the 
trunk, about the nose, and within and about the concha of the ear. 
The lesions are often traversed by a hairy filament. In some cases the 
affected regions are so thickly invaded that the resulting scars produce 
a cribriform aspect in the integument. Occasionally the arrangement 
of the lesions is linear or is circinate. 

The variations displayed are exceptional, but worthy of note. Severe 
confluent, serpiginous, and very extensive development of the malady 
may be seen. According to Boeck, the hue of the papulo-pustule is 
due to minute capillary hemorrhages, which later become invisible in 
consequence of the tumefaction of the overlying integument. 

Etiology. The sexes are represented nearly equally among the sub¬ 
jects of the disease, who are, as a rule, in or near middle life. There 
is often a history of syphilis, in which event the disease should always 
be classed with the syphilodermata. 


388 


DISEASES OF THE SKIN. 


Pathology. According to Boeck, the local disorder results from a 
hyperplasia of the totality of the epidermis, especially noticeable about 
the external root-sheaths of the hairs, which penetrate the corium in 
the form of somewhat dense cones. The sebaceous glands are not 
noticeably altered in size, the vascular capillaries are commonly dilated 
and distended with blood, and minute extravasations are here and there 
visible. The pars reticularis of the corium often undergoes necrosis 
in its entire thickness. 

None of the authors touching upon this theme has yet studied these 
troubles from the standpoint of tubercle-infection. Some of these 
cases may be due (as suggested of erythema acneiforme in the chapter 
on Tuberculosis) to infection with tubercle-bacilli. Acne varioli¬ 
formis occurs in typical development upon the faces of the tuberculous. 

Diagnosis. The lesions are to be distinguished from the syphilo- 
derm named above, from acne vulgaris, and from variola. The points 
of distinction are: the absence of fever, present and precedent; the 
absence of other symptoms of syphilis; the localization of the eruption; 
and the absence of intermingled comedones and other symptoms of 
acne disseminata. The involvement of the scalp-surface is not alone 
sufficient to distinguish it, as syphilodermata and occasionally come¬ 
dones are visible above the brow in the scalp. 

Treatment. In all syphilitic cases the treatment is that of the con¬ 
stitutional condition. Locally, the use of mercurial and resorcin 
salves, with the application, in severe cases, of caustics or galvano- 
puncture, is required. 


IMPETIGO HERPETIFORMIS. 

Impetigo herpetiformis is a cutaneous disease of women, frequently complicating 
the puerperal state, characterized by the occurrence upon the skin and the 
mucous membranes, of concentrically grouped pustules, and by a febrile condition 
which usually terminates fatally. 

Symptoms. Knowledge of this rare disease is limited to the reports 
of thirteen cases observed by Hebra and Kaposi in the Vienna clinic; 
one by Heitzmann in New York; one by Pataky; and a few scattered 
cases reported by others. Of the Vienna patients, twelve were women, 
and these were usually in the puerperal state. 

Pin-head-sized pustules, usually closely packed together in groups, 
filled with an opaque or a yellowish-green fluid, are discovered upon 
the surface of the groins, the navel, the axillae, the breasts, and other 
portions of the body. A dirty brownish-colored crust is formed by 
the rupture or the desiccation of these lesions, and about this crust, 
single, double, or triple concentric circlets of new and similar lesions 
appear in succession, each series undergoing a similar process of invo¬ 
lution. The eruption thus extends until the circlets from different 
foci of origin unite, and extensive areas of the skin are involved. 
Beneath the crusts the skin is reddened, infiltrated, smooth, and cov¬ 
ered with a new epidermis, moist as in eczema, or exhibiting a denuded 


INF LAMM A TIONS. 


389 


corium. It is never in a state of ulceration. In the course of three 
or four months the eruption is well-nigh universal, the skin being 
swollen, shining, and crust-covered, or seamed here and there with 
excoriations, surrounded by circles of pustules. The lingual mucous 
membrane exhibits grayish, centrally depressed patches, well defined 
in contour. Alternate rigors and febrile accesses mark the periods 
of recrudescence when new pustules form. Delivery seems to have 
no favorable effect upon the course of the disease occurring in preg¬ 
nant women. An endometritis with peritonitis was discovered, post 
mortem, in a single case. Two women only of the thirteen Vienna 
patients survived; and one suffered from a relapse after several weeks 
of improvement. 

The etiology and pathology of the disease are necessarily obscure, 
having in view the relatively small number of reported cases. Duhr- 
ing describes a much milder malady of similar type, occurring in 
women not pregnant, and latterly has included impetigo herpetiformis 
in the list of diseases covered by the title, dermatitis herpetiformis; 
but Kaposi refuses to admit any such reduction of impetigo herpeti¬ 
formis to a class of other maladies. Robinson also described a case 
supposed to represent one of the mild manifestations of the disorder. 
Kaposi is inclined to associate the disease with a pathological condition 
of the uterus. Heitzmann thinks it related to pemphigus. Besnier 
and Doyon conclude the disease to have a septicemic origin. 

The diagnosis of the disease is between herpes, dermatitis herpeti¬ 
formis, and pemphigus. 

In herpes the purely vesicular character of the lesions and the 
cyclical career of the disease indicate its nature. In dermatitis her¬ 
petiformis there is commonly a distinct multiformity of lesions, and 
the subjects of the disorder are not, in such great preponderance, preg¬ 
nant women. In pemphigus the size of the bulles and their dis¬ 
tribution in other than concentric groups will indicate the character 
of the disease. 

The treatment is conducted on general principles, including the admin¬ 
istration of antipyretics, and the local employment of alkaline, or of 
carbolated baths; starch and other dusting-powders; anodyne, carbo- 
lated or simple salves; and a mixture of plaster and coal-tar. The 
uterus should be relieved of its contents. 

The prognosis is necessarily grave. 


390 


DISEASES OF THE SKIN. 


PEMPHIGUS. 

(Gr. 7 refjtyi!;, a bladder.) 


(Pompholyx. Ger., Blasexausschlag.) 

Statistical frequency in America, 0.148. 

Pemphigus is an acute or a chronic disease of the skin, often characterized by febrile 
and other symptoms of constitutional disturbance, accompanied by the production 
of a series of pea- to egg-sized, oval or spherical bullse, irregularly distributed 
over the affected surface, and distended with serum or with blood. 

With respect to the question whether pemphigus should be regarded 
as the name of a distinct disease, or of a group of several diseases, 
various opinions are held. At one time every dermatosis displaying 
blebs was accounted a form of pemphigus. With increasing knowledge 
there has been a greater reluctance to distinguish any disease, merely 
because of a bullous exanthem, by this specific term alone, and as a 
result a number of affections, with bullous efflorescences upon the 
cutaneous surface, have been wholly disassociated from both pemphigus 
and what the French term the u pemphigoid eruptions/* For some 
authors there is only a chronic pemphigus; for others, in order to 
establish a diagnosis of pemphigus, the existing lesions should repose 
directly upon the skin without exhibiting a peripheral inflammatory 
areola, or at least be the expression of a disease with periodic exacer¬ 
bations in a determined career. 

In many morbid conditions of the skin bullse are present when it is 
manifestly improper to call the disease pemphigus. For example, 
these lesions are exhibited typically in some forms of lepra, in inher¬ 
ited syphilis, often as a result of the traumatisms of insects, and of 
several infective processes. To assert that a disease is a pemphigus in 
one of its varieties, it is necessary to recognize the presence of other 
symptoms than bullse. 

The distinctions respecting the bullous dermatoses established by 
Brocq are worthy of recognition. In a first class are included, as 
suggested above, the bullse, which are epiphenomena of some malady 
(e. g., erysipelas). In a second class the bullse are either the main 
feature, or one of the main features of a disease. The second class 
includes both the dermatoses in which the eruptive symptoms are not 
commonly of bullous type but which become such under special con¬ 
ditions ( e.g ., polymorphous erythema bullosum), and those eruptions 
to which the term 'pemphigus is assigned by the best authors. 

It is to this second class, and to the last-named subdivision of the 
class, that the title is assigned in the paragraphs which follow. In 
this group are included: (a) Acute pemphigus; (6) Chronic pemphigus; 
(c) Pemphigus foliaceus; ( d) Pemphigus of the newborn; (e) Pem¬ 
phigus of young girls; (/) Pemphigus vegetans, of Neumann. 

It should be understood at the outset that these are simply clin¬ 
ical distinctions of value for the time being. There are doubtless other 
forms of pemphigus, some of which are named below; and there are 


INFLAMMA TIONS. 


391 


unquestionably morbid conditions here described which may later more 
appropriately be classed with other affections. 


Acute Pemphigus. 

The rarity of this disorder has led observers to deny its existence. 
It is seen, however, though very rarely, in typical expression, chiefly 
in infants and in young adults. 

Acute pemphigus occurs in adults, in children, and in infants, but 
more frequently among the very young. It may be epidemic in hos¬ 
pitals and in other public institutions. With or without an antecedent 
febrile movement, the blebs may appear before or within a fortnight 
after birth, in infants which are well-nourished or cachectic, more often 
the latter. In favorable cases the evolution of the disease is com¬ 
pleted within three or four weeks. Any part of the body may be 
affected; but, what is important from a diagnostic point of view, the 
face, the hands, and the feet are often exempt. The conjunctiva and 
mucous lining of the mouth, may, however, become implicated. In 
some cases the pemphigus may be of hemorrhagic type. Underneath 
the lesions the rete is exposed, and it has a reddish, glistening look. 
The termination may be fatal. Acute pemphigus of adults is still 
rarer. As in the case of infants, in adults there may be marked febrile 
antecedents and systemic disturbance. The eruption of pea- to large 
nut-sized bullae may be sparse or be abundant, covering in some cases 
the entire body, and attacking mucous surfaces. The vesicles or bullae 
may be tense, flaccid, and filled with clear, serous, or puriform con¬ 
tents. Covering the floor of the lesion may be seen a smooth, raw, 
mucous layer or a diphtheritic exudation. According to Weyl, Bulk- 
ley’s Herpes gestationis is an example of Acute pemphigus adultorum. 

The bullae, as a rule, are large, well-formed, and irregularly distrib¬ 
uted over the body, the face, and the limbs, with acuity of develop¬ 
ment. After a few hours or a few days crusts form, the latter, after 
their fall, leaving a slightly pigmented surface beneath. In the case 
of infants the greatest care is required to differentiate the disorder 
from syphilis, commonly not a difficult matter, since the eruptive 
symptoms in syphilis are first developed, as a rule, at a later period, 
are less acute, and they invariably exist upon the person of an infant 
exhibiting the characteristic cachexia of lues. 


Chronic Pemphigus. (Pemphigus Vulgaris.) 

The term Pemphigus Vulgaris is applied to the more common clin¬ 
ical forms of the malady, and it has been employed genetically by 
many authors to include all varieties of the disease. The title Pem¬ 
phigus Diutinus has also been employed to designate that pemphigoid 
eruption in which the characteristic lesions follow each other with 
rapidity and in profusion, fresh bulke appearing each day. Fortu¬ 
nately, all forms of the disease are relatively rare. 


392 


DISEASES OF THE SKIN. 


Symptoms. The cutaneous lesions in chronic pemphigus are usually 
preceded by febrile symptoms; and the disturbance of the economy is 
declared in cardiac, respiratory, and gastro-intestinal derangements of 
function. The fever may be continuous, remittent, or intermittent, and 
is usually exaggerated just before the appearance of a fresh crop of blebs. 

The face, the trunk, and the extremities are chiefly involved. The 
eruption first appears bilaterally, somewhat symmetrically or asym¬ 
metrically, in reddish macules of rather vivid hue, in the centre of 
each of which appears later a whitish elevation of the epidermis sug¬ 
gesting a wheal. Either upon these or upon unaffected points of the 
skin there subsequently form tense, well-rounded, or oval vesicles 
developing into bullae varying in size from that of a pea to that of a 
hen’s egg, and even larger, and in number from three to six only, to 
a hundred and more; they are usually irregularly distributed (Pem¬ 
phigus Disseminatus), but they may be clustered in groups, or very 
rarely be found the younger encircling the older lesions, so as to form 
a circinate patch (Pemphigus Circinatus); their contents are serous, 
or bloody (Pemphigus Hemorrhagicus), or, later, purulent, the 
color corresponding with pus. The bullae often coalesce, and, whether 
ruptured or not, the involution of the lesion is accomplished by desic¬ 
cation and crusting, the crusts being usually found to contain blood, 
pus, epithelial debris, and the exudate from the base of the bleb. 
Beneath such a crust there forms a new epidermis, which is usually 
violet, purplish, or bluish-red in color, and which, later, displays a 
brownish pigmentation which may for several weeks survive the disease. 

Occasionally the affection occurs with very mild and even insignifi¬ 
cant phenomena (Pemphigus Benignus). There may be no fever, 
and very few blebs appear; in some cases but a single lesion can be 
seen (Pemphigus Solitarlus). In other instances the fever is intense, 
the eruption abundant, the skin oedematous, painful, pruritic, excori¬ 
ated, and the underlying lymphatic glands are enlarged. This general 
condition with exacerbations and remissions may persist for months, 
and the eruption may then disappear never to return, or to recur, as 
it often does, in the future. 

Clinically, many of the distinctions between the varieties of pem¬ 
phigus disappear. Between the benign processes just considered and 
the grave form of pemphigus foliaceus described below, several inter¬ 
mediate gradations can be observed, and even the most benign may at 
times unexpectedly assume the most malignant phases. Pemphigus 
Malignus is a name given generally to those intermediate varieties of 
the disease, most of which are distinguished by persistent and pros¬ 
trating fevers; by cachexia, especially in infants; by the occurrence 
of diphtheritic patches upon or about the lesions, with infiltration of 
the derma and slough of its superficial layers; or by extensive crust¬ 
ing, and even subsequent ulceration. A form is described by Hebra 
and Kaposi in which vegetations and fungosities rise from the base of 
the blebs. 

Pemphigus Pruriginosus is another grave form of the disease, 
in which the lesions give rise to an intense pruritus. Under the 


INFLAMMA TIONS. 


393 


scratching induced by the pruritus they are torn, excoriated, and com¬ 
mingled with the crusts and exudations of an artificially engendered 
eczema. If the itching be severe, the vesico bullae may be so torn as 
to be difficult of recognition. Several of the malignant and intermedi¬ 
ate forms may terminate fatally. 

In all varieties of pemphigus the lesions may be exhibited upon the 
mucous membrane of the accessible outlets of the body. 

Chronic pemphigus exhibits the greatest variation both as to its 
symptoms and to the period of their efflorescence. There may be a 
week or a month of immunity, followed by benign relapses, or by 
malignant and rapid recurrences. The bullae may form upon an unal¬ 
tered or a deeply hyperemic skin, in all sizes from the size of a pea to 
that of an orange, invading the skin and mucous surfaces including the 
vagina, the lesions at the base exhibiting the several features described 
above. The eruption is rarely generalized, and throughout the course 
of the disease not more than half a dozen lesions may at any moment 
be visible upon the surface of the skin. Their contents may be removed 
by evaporation, absorption, or rupture, leaving a crust whose color is 
largely determined by the contents of the bleb. 

The areola, which may or may not be present in the several forms 
here described, is commonly narrow, and is fully developed only when 
the bleb is mature. The separate lesions may persist for days, or may 
rupture at an earlier period, leaving behind a superficial excoriation 
which, after healing, exhibits some pigment. 

The intercurrent disorders in the several forms of the disease desig¬ 
nated may be numerous, death occurring from septicemia, exhaustion 
(especially when the deeper slough results, as in pemphigus gangrse- 
nosus), and lymphangitis, the neighboring vessels and glands exhibiting 
evidence of the toxic effects produced by the cocci present. In some 
cases the general symptoms are absent or are insignificant, and the 
subjective sensations are limited to a slight feeling of burning or of 
tension. In other cases the blebs project completely from the affected 
surface and are well distended; in still others they are flaccid, the roof 
partially collapsing upon the serous, purulent, or bloody contents. The 
crusts which form are rarely bulky; they are more commonly dark 
colored and thin. 


Pemphigus Poliaceus. 

Pemphigus foliaceus is an exceedingly rare variety of dermatosis, 
which may originate in a grave form of pemphigus chronicus, or may, 
at the onset, present characteristic features. Hallopeau and Fournier 
have reported cases which began as a dermatitis herpetiformis. The 
lesions are flaccid bullae, which are developed without a perceptible pre¬ 
existing exanthem, and which speedily rupture and discharge their ill- 
conditioned contents, leaving beneath an excoriated, reddish or pur¬ 
plish, and at times inflammatory surface. Often the blebs are so poorly 
defined that the epidermis seems scarcely raised from the tissue beneath, 
the condition resembling that of the skin to which a blister has been 


394 


DISEASES OF THE SKIN. 


applied, with the result of imperfect vesication. The contents, at first 
pellucid or lactescent, become later purulent or sanguinolent. When 
rupture of the blebs occurs there form yellowish-brown crusts which 
acquire a feeble attachment to the centre of the floor of the original 
chamber, while the edges remain free; these edges, visible over the 
affected surface, in poly cyclical or irregular outlines, incompletely 
hiding the raw and ill-conditioned epidermis, give a characteristic 
picture to the skin. . \ 

The disease spreads gradually until it becomes symmetrical and 
universal, a peculiarity which marks it as unique among the pem¬ 
phigoid eruptions, and which, in a striking degree, distinguishes it from 
pemphigus vegetans and from pemphigus acutus. As the disease 
advances the patient lies in a pitiably helpless condition, the remain¬ 
ing epidermis being completely undermined by the serum exuded, in 
places exposing large denuded areas of skin in a condition of inflam¬ 
mation of a low grade. 

The disease affects the mouth and throat, denuding the mucous 
surfaces of epithelium; the scalp becomes affected, as also the covered 
portion of the body, but the hairs remain attached for a long time. 
Over the face, which was at first merely reddened and scaling, occur 
retractive accidents which at times produce ectropion and consequent 
conjunctivitis. Over the body, especially at points pressed upon 
when reclining, profound ulcerations may destroy the deep skin. The 
palms and soles are infiltrated and fissured rather than the seat of much 
exudation. The nails are commonly furrowed and distorted; occa¬ 
sionally they are shed. The subjective sensations are those of burn¬ 
ing, smarting, and soreness, rather than of itching. If the patient 
be kept in the continuous water-bath, though the disease be not thereby 
ended, the comfort of the sufferer is admirably secured. 

There may be no fever, or there may be a recurrent rise of body- 
temperature, with recurrence of lesions which, in a late stage of the 
disease, appear in the sites of those which have been very imperfectly 
followed by attempts at repair, a thin and glazed epidermis forming, 
in cases of chronic type, where bullae once reposed. The disease may 
accomplish its course iu a few months or may persist for years, and 
though not necessarily, yet is unquestionably fatal in the majority of 
all cases. Death usually results from exhaustion ; occasionally, an 
intercurrent pneumonia or diarrhea concludes the history. 


Pemphigus Neonatorum. 

The disease to which this name is given should not be confused with 
pemphigus acutus (described above), which may occur both in the new¬ 
born and in young adults. Pemphigus neonatorum is a term which 
describes an affection observed exclusively in children. The lesions 
are ill-developed bullae, which appear in cachectic infants soon after 
birth, who have been subjected to the worst hygienic influences. The 
eruption usually occurs about the lower portions of the trunk, as these are 
the regions requiring most, and, in these unfortunate beings, receiving 


INF LAMM A TIG NS. 


395 


least care, with respect to cleanliness. In some cases children healthy 
in appearance are suddenly seized with an attack, the skin, accord¬ 
ing to Fox, becoming livid, the bullae being surrounded with dark 
areolae, and ulcers forming as a result of gangrenous complications. 
These are probably cases of infection with pyogenic cocci in ill- 
nourished infants, where the reaction of the skin is expressed in a 
bullous rather than in a pustular efflorescence. The subjects usually 
perish in a few days, but they may survive if speedily placed in a 
hygienic environment. Infants thus affected are to be carefully dis¬ 
tinguished from those suffering from inherited syphilis and exhibiting 
a bullous sypliiloderm on the body. 

An inherited form of pemphigus is described by Goldscheider, Legg, 
and others, where several members of one family, upon being subjected 
to the slightest external irritation of the integument, suffered from 
a bullous eruption at the site of the irritation. These phenomena are 
said to be most often noticed in summer, spring, or autumn; rarely in 
winter. 


Pemphigus of Young Girls. 

This disorder, described by Hardy 1 under the title “ Pemphigus 
Virginum,” is characterized by the appearance upon the skin of oval 
or rounded spots of a reddish or rosy hue; upon these spots there later 
develop vesico-bulhe of different sizes, which it has been suspected 
are, in some subjects, instances of feigned eruption {q.v.). The sub¬ 
jects of the disease are between the fourteenth and the twentieth year 
of life, unmarried, and usually menstruating irregularly. Others have 
described a “ pemphigus hystericus,” to be recognized in hysterical 
persons of the same class, alternating or corresponding with hys¬ 
terical attacks, the eruption not uniformly disposed over the surface, 
and being transitory in duration, disappearing with relative rapidity 
and leaving no cicatricial traces of its existence. 


Pemphigus Vegetans 

Neumann 2 was first to describe and furnish illustrations in color of 
a disease to which he gave this name, and which has since been studied 
by a number of observers. Crocker, 3 of London, published an excel¬ 
lent monograph, giving tabulated results in some eighteen cases; and 
at the meeting in 1891 of the American Dermatological Association in 
Washington, the author 4 of these pages read a full account of the first 
case reported as such in the United States, the patient having been seen 
in connection with Duhring, of Philadelphia. 

The onset of the disease is marked by languor, malaise, and ill- 
defined symptoms of poor health, after which the surface-symptoms 
may first be declared in the mouth or the skin. In the former region 

1 Traite prat, et descript, des Mai. de la Peau, Paris, 1886, p 268. 

2 Vierteljahrschr. f. Derm. u. Syph., 1886, Bd. xiii. 

3 Pemphigus Vegetans (Neumann), London, 1890. 

4 Journ. Cutan. and Gen.-Urin. Dis., Nov. and Dec. 1891. 


396 


DISEASES OF THE SKIN. 


white patches, which are ill-developed blebs, are visible upon the mucous 
surface. The detached membrane forming each spot is finally loosened 
and leaves behind equal-sized excoriated patches, which produce exces¬ 
sive soreness of the mouth, and which as some heal are succeeded by 
others. In severe cases they render mastication and deglutition exqui¬ 
sitely painful; and in patients where this becomes a prominent feature 
of the case the nutrition of the body is seriously impaired. 

The skin-lesions may precede or may follow those in the mouth. 
They are commonly first seen in women about the vulva, spreading 
over the ano-genital region as closely set bullae covered with a mucoid 
whitish secretion, the features thus strongly resembling the appearance 
of condylomata of the same region. In connection with the mouth- 
lesions, the suggestion that syphilis is present is very striking, and has 
led to this error of diagnosis in the larger number of instances reported 
by those not expert in its recognition. The bullous efflorescences, which 
at first resemble those of other forms of pemphigus, speedily exhibit 
in the site of their production vegetating masses, the change from the 
bleb to a fungoid papillomatous growth being scarcely appreciable. 
The lesions tend to become grouped about the axillae, the circle at the 
root of the neck, the bend of the elbows, the hands, the feet, and the 
scalp, but they have no tendency to become universal, even when quite 
extensive. A singular change in the skin, where typical, well-formed 
bullae have developed and healed, is a deep pigmentation in puncta 
resembling comedones, with pin-point-sized verrucoid elevations of 
the surface. In some regions the sequence of the closely packed blebs, 
followed by vegetating masses, resembles that seen in pemphigus folia- 
ceus, where, especially over the back after a long decubitus, there form 
large, raw erosions, exquisitely painful, and hastening the patient to 
the end. The disease progresses in unmistakable accessions of aggra¬ 
vation and improvement, lasting for months and occasionally for years. 
It is, however, in the vast majority of all cases, eventually fatal, but 
one or two of about threescore patients have been reported as cured. 
Variations occur, chiefly in the line of the degree of febrile tempera¬ 
ture, probably always reactive; in the severity of the buccal lesions; 
and in the extent of the eruption. 

Treatment. Internal treatment is by resorbent measures; locally, 
the continuous immersion of the patients in water at the temperature 
most grateful to the skin affords speediest relief. The surface is to 
be carefully dusted with borated, salicylated, or camphorated powders. 
The numerous scalp-lesions require cutting short the hairs of the 
head in order to make applications. Alcoholic stimulants are in most 
cases essential. 

Etiology . The causes of pemphigus are obscure; yet the connection 
of many varieties of the disease with changes in the trophic nerves 
and nervous centres is established by sufficient proofs. It is well known 
also that traumatisms and lesions of the cord have been followed by 
bullous efflorescence upon the body-surface. At the same time (as 
Kaposi has well shown), on the one hand, blebs from these demon¬ 
strable causes never resemble the portraits distinguishable in the varie- 


INF LAMM A TIONS. 


397 


ties of pemphigus; and, on the other hand, there is no uniformity among 
lesions, either as to anatomical site or other features, in the spinal 
changes to be recognized in pemphigus Avith a fatal issue. Further, 
of nine autopsies of bodies dead of pemphigus, examined by Kaposi 
and Weiss, in only one were changes found in the cord (diffuse sclero¬ 
sis). The view that these dermatoses are instances of infective trouble 
is, therefore, gaining ground, and it is quite probable that future 
investigation will demonstrate that both the cutaneous and the nervous 
lesions are the results of a toxic agency operating with morbid results 
upon each. 

Pemphigus is more frequently encountered in males, and among 
these in infancy and childhood, because the powers of resistance at a 
tender age are inferior to those of a maturer epoch. The disease is 
often observed in debilitated patients, who are variously described as 
suffering from “nervous prostration/’ “mental worry and exhaus¬ 
tion,” “ neurasthenia,” “ general debility,” visceral disorders, and 
impairment of nutrition. In vigorous, rosy-cheeked, strong-limbed 
adults the disease certainly is very rare. Those states in which there 
is marked impairment of bodily vigor are particularly favorable to 
the development of the disease. 

Kaposi relates one history in which the inherited variety of pem¬ 
phigus is illustrated, as the patient’s mother, sister, mother’s brother, 
and some of the children of the latter, had been affected with the 
malady. While, however, this author admits such association of nervous 
disorder with the disease as occurs in hysteria and pregnancy, he con¬ 
cludes that there is little if any etiological significance in the fact. 
The author of these pages has, however, observed one case of the dis¬ 
ease in an adult where pemphigus of typical appearance occurred after 
mental depression, which was so greatly increased by the appearance 
of the exanthem as to lead to suicide. 

There is good reason to believe that, at least in some of its forms, 
the disease is contagious. The bullous lesions, however, seen in syph¬ 
ilis, lepra, and other similar disorders, should not always be here 
included. 

Pathology. Anatomical changes in the spinal cord (diffuse sclerosis) 
have been recognized in pemphigus, as explained above. Jarisch dis¬ 
covered swelling of the processes of the ganglion-cells and interstitial 
fibrous deposits in a similar case. DejSrine and Leloir found changes 
in the peripheral nerves due to degeneration in a case of pemphigus. 

The contents of the bullae of acute pemphigus were found by Gibier, 
in 1882, to contain bacteria. The microbes recognized by him were, 
when mature, arranged in chaplets, each containing a series of joints. 
His observations were confirmed by Vidal and Koeser. Kiehl, in 1883, 
discovered both conidia and spores in the layer of epidermis beneath 
the lesions of infantile pemphigus. Demme, 1 in 1886, found cocci 
both in the contents of the bullae and in the blood. 

Thin, of London, 2 however, after full trial of all methods of stain¬ 
ing and cultivation now employed, had entirely negative results in his 


i Viertel. f. Derm. u. Syph., 1886. p. 636. 


2 Lancet, May 30, 1886, p. 981. 


398 


DISEASES OF THE SKIN. 


attempts to discover micro-organisms in the contents of the bullae of 
pemphigus. 

Diagnosis. From what has preceded it will be inferred that pem¬ 
phigus is a name given to a disease, and not merely to bullous lesions 
upon the surface of the skin. It is of some importance to remember 
this fact, as several authors have used the term in a purely descriptive 
sense, the truth being that bullae are manfestations of several disor¬ 
ders, including syphilis, lepra, pemphigus foliaceus, herpes iris, and 
erythema multiforme. 

At the outset the blebs of pemphigus can scarcely be differentiated 
from those of other diseases. It is necessary for the recognition of the 
malady that proper consideration be had of all the cutaneous and other 
phenomena present in the disease. In syphilis blebs are rare in the 
adult, and relatively more frequent in infants hereditarily diseased. 
With infants the blebs are usually seen at birth, often upon the palms 
and soles, and are frequently superimposed upon an exulcerated base. 
The coexistence of mucous patches of the mouth, the vulva, and the 
anus with the evideut polymorphism of the lesions and signs of grave 
cachexia, will usually indicate the nature of the disease. The cuta¬ 
neous symptoms of infants thus affected are improperly designated as 
pemphigus. Such an eruption is a bullous syphiloderm. 

In the bullae of lepra there is usually coexisting cutaneous anesthe¬ 
sia, and the involution of the bleb is followed by a strikingly char¬ 
acteristic atrophic patch, usually pigmented and insensitive. In 
pemphigus foliaceus the extraordinary and usually generalized des¬ 
quamation which ensues is sufficiently distinctive, though it must be 
borne in mind that the several varieties of pemphigus may be trans¬ 
formed, the one into the other, by well-nigh insensible gradations. 
Among its graver forms susceptible of such transformation may be 
named impetigo herpetiformis, pemphigus cachecticus, pemphigus 
diphtheriticus, and pemphigus prurigiuosus. 

In herpes iris the lesions are more vesicular than bullous and 
much more transitory; are subject to a concentric arrangement and 
variation with respect to color; and are situated more frequently upon 
the extremities, especially the backs of the hands. The bullous 
lesions occasionally seen in urticaria and erythema multiforme are to 
be recognized by the other characteristic symptoms of these diseases; 
in the former, more particularly, by their intermingling with typical 
wheals, and in the latter by the location of the eruption, and its cli¬ 
matic or seasonable significance. Some of the reported contagious 
forms of pemphigus, epidemics of which have been described by Bes- 
nier, Hervieux, and other French authors, were possibly, as Duhring 
suggests, instances of impetigo contagiosa. This inference is sus¬ 
tained by the frequent allusion of the writers named to the “varicella- 
form ” appearance of the lesions. 

In a singularly large proportion of cases pemphigus vegetans has been 
mistaken for syphilis, the close grouping of the lesions about the ano¬ 
genital region, and their striking resemblance to condylomata, taken 
in connection with the presence of erosions of the mucous membrane 
of the mouth, being the grounds for error. With care, this blunder 


INFLAMMA TIONS. 


399 


can usually be avoided. However closely packed together may be 
condylomata of this region, they almost never spread, as does pem¬ 
phigus vegetans, beyond the regions adjacent to the mucous outlets; 
while the bullae of pemphigus vegetans are not only, when the disease 
is fairly advanced, exceedingly numerous and closely packed together, 
but they spread also beyond—high toward the pubes and low along the 
inner faces of the thighs. In the latter event, also, there is commonly 
a history of fever, no lymphatic adeuopathy, and a distinct uniformity 
of lesions, each separate element being of bullous type. Some in¬ 
gested medicaments are capable of producing bullous lesions, for 
example, iodid of potassium ; such a possibility should always be 
borne in mind when establishing a differential diagnosis. Scabies in 
infants and older children is occasionally characterized by the forma¬ 
tion of blebs, in which case the other lesions present, as also a history 
of contagion and the discovery of the parasite, will point to the real 
nature of the disease. 

Lastly, the external application of cantharides, mezereon, the stronger 
acids, alkalies, and other chemicals, may be followed by blebs produced 
either by accident or by intention with a view to feigning disease. 
The intentional production of such symptoms is usually effected upon 
the anterior faces of the lower extremities, regions within easy reach 
of the right hand. Erysipelas and dermatitis calorica are also diseases 
in which blebs appear, always, however, of minor significance as com¬ 
pared with the other symptoms of disease present. The same may be 
said of the bullae which form upon a gangrenous integument. 

Treatment. The internal treatment of pemphigus is a matter of im¬ 
portance, as will be suggested by even a brief consideration of the 
constitutional states in which it occurs. Jonathan Hutchinson, of 
London, in his valuable Lectures on Clinical Surgery, 1 distinctly asserts 
his belief that “ arsenic is a specific for the state of health upon which 
relapsing pemphigus depends.” In many years’ trial of this remedy 
he declares that, in his own practice, he has never recorded a single 
failure, though he makes exception, properly, of many infantile cases 
supposed to be syphilitic. This remedy is certainly a valuable one, 
but it should be employed with caution and in accordance with the 
rules already prescribed in the chapter on Psoriasis. Kaposi, however, 
declares that he has been unable to obtain favorable results from its 
employment. Iron, quinin, ergot, strychnin, and the mineral acids 
are certainly indicated in many cases, in conjunction with a particularly 
nutritious diet. Cod-liver oil aud the malt preparations now on the 
market should not be neglected. 

Not infrequently the treatment should be directed to the relief of 
the anomalous performance of the sexual function in women, as pem¬ 
phigus has been found to occur in the hysterical and chlorotic states 
sufficiently common as a result of functional disorder. 

The local treatment of the lesions should consist, first, in puncturing 
each bleb with a fine needle, in order to give exit to its contents, which 
should carefully be removed from the skin by the aid of cotton-wool. 

i London, J. & A. Churchill, 1878, p. 49. 


400 


DISEASES OF THE SKIN . 


Then the parts are to be wholly enveloped in an inert or borated 
dusting-powder. When there is considerable pyrexia, with heat and 
distress in the skin, the affected surface may be treated as in acute 
eczema, with oleated lime-water, containing opium or dilute hydro¬ 
cyanic acid in some such proportions as those already detailed. 

The ordinary lead-and-opium wash, with or without the addition 
of oxid of zinc, will also answer a good purpose. In Vienna the 
continuous hot-water bath still enjoys the highest favor in the treat¬ 
ment of the grave forms of pemphigus. Kaposi kept one patient day 
and night for eight months with his body thus immersed, to the great 
advantage of the invalid. This continuous bath is often impracticable 
outside a large hospital; but incases of grave pemphigus the con¬ 
tinuous hot-water bath has been employed in private practice with the 
happiest results. 

Prognosis. The prognosis in mild cases of pemphigus, though much 
less grave than in the malignant forms of the disease, should always 
be formulated with caution. Unlike several of the diseases heretofore 
considered, the affection is one not frequently encountered in persons 
of fair general health. The constitutional condition of the patient 
must carefully be considered ; it should not be forgotten that the disease 
is not only one liable to relapses, but also is one in which the graver 
may succeed the more benign manifestations. A flaccid summit of the 
bleb, sanguinolent or ichorous contents, an abundant efflorescence,, and 
a rapid succession of new, after the involution of more ancient, lesions, 
are in general unfavorable symptoms. The same may be said of degen¬ 
eration of the floor of the bleb, after rupture and discharge of its 
contents. 


HYDROA. 

(Gr. vdop, water.) 

The term hydroa was once extensively used as a designation of cuta¬ 
neous disorders characterized by the occurrence of a bullous exanthem, 
the blebs being associated with erythematous lesions and productive 
of subjective sensations of itching. It is no longer employed by the 
best authors as a title of disease; it is here set down merely in order to 
enumerate some of the affections liable to be confounded under this title. 
The Herpetiform hydroa, of T. Fox; the Dermatitis herpetiformis, 
of Duhring; the Herpes circinatus bullosus, of Wilson; the Hydroa, 
of Quinquaud; the Herpes gestationis, of Bulkley; and the Pemphigus 
pruriginosus, of Chausit and Hardy, are included by some authors 
under the name hydroa. According to Quinquaud, the essential symp¬ 
toms of hydroa are: a primary vesico-bullous exanthem; a rapid evo¬ 
lution of symptoms; the termination of the disorder within two months 
as a maximum ; the occurrence of pruritus in the active periods of the 
disease; and the recognition of varieties, pemphigoid, impetiginous, 
vesicular, circinate, regional, and of a form implicating the mucous 
surfaces. 

Crocker describes a group of diseases by this name, u standing mid¬ 
way between erythema multiforme and pemphigus.” The most of 


INF LAMM A TIONS 


401 


them, even on the showing of French writers including Bazin, can 
without difficulty be assigned to the one class or the other. 

Of the three varieties of hydroa proposed by Bazin, Hydroa vSsicu- 
leux is identical with the Erythema and Herpes iris of Bateman, and 
Hydroa bulleux is a phase of dermatitis herpetiformis. As a result 
of recent observations Hydroa vacciniforme would seem entitled to 
consideration as a distinct disease. 

Hydroa Vacciniforme, seu ^Estivale. 

(Hydroa Puerorum.) 

This form of hydroa, first described in 1855 by Bazin, has not been 
recognized by more modern writers until quite recently. Hutchinson, 
Handford, Jamieson, Boeck, Crocker, Bowen, Graham, and others have 
seen and described a number of cases of hydroa vacciniforme. The 
following description is taken chiefly from those of Crocker 1 and Bowen : 2 

The disease usually begins during the first three or four years of life 
and gradually disappears during the few years following puberty. With 
but two or three exceptions the cases reported have been iu boys. The 
disease is most active in summer, the larger number of the patients 
remaining free from active manifestations during the winter months. 
The direct cause in most cases has been exposure to the sun’s rays, 
though exceptionally warm or cold winds, or even artificial heat, seemed 
to be sufficient to cause an outbreak. 

The eruption is symmetrical and is limited to the uncovered parts 
of the body; the bridge of the nose, cheeks, and ears, and the backs 
of the hands being the parts most affected. Bazin, however, reported 
cases in which covered portions of the body were slightly involved. 
The disease occurs in successive outbreaks, each of which lasts for two 
or three weeks. The intervals between recurrences in the summer may 
be several weeks, or so brief as practically to be wanting. The lesions 
first to appear are red macules or elevations, upon which are rapidly 
formed vesicles or bullae, varying in size from that of a millet-seed to 
that of a large pea, and occurring either singly or in groups like 
herpes ; they may coalesce. These vesicles may dry in a day or 
two, or they may rupture and form a crust, but many of the larger 
become depressed in the centre and resemble a vaccination-vesicle. 
The depressed centre is black or dark blue, and is surrounded by a 
ring of fluid, while about the whole is a reddened areola. Some of 
the lesions may become purulent. The black centre is rapidly con¬ 
verted into a thick, black crust which is very adherent, and which on 
falling leaves a depressed, reddened scar that eventually becomes white 
and practically indistinguishable from that of variola. The duration 
of an individual lesion from its beginning to the formation of the crust 
is three or four days. The time required for the crust to fall is variable. 

The eruption is usually preceded by some slight constitutional dis¬ 
turbance, and by burning or pain at the site of the lesions. Itching is 
absent, as a rule, though it was quite marked in Bowen’s case. 


1 Diseases of the Skin, 1893. 


2 Journ. of Cutan. and Gen.-Urin. Dis , March, 1894. 
26 


402 


DISEASES OF THE SKIN. 


The pathology has been studied by Bowen in two lesions taken from 
a single case. In the primary stage he found merely vesicle-forma¬ 
tion in the middle layers of the rete. In a more advanced lesion he 
found necrosis involving the lower layers of the stratum corneum, the 
entire rete, and the corium nearly to the subcutaneous tissue. He 
concluded that the process begins as an inflammation in the epidermis 
and upper part of the corium, followed by vesicle-formation in the 
rete, and later by the necrosis described above. The necrosis is quite 
sharply circumscribed, and, showing through the vesicles above, pro¬ 
duces the black centre of the advanced lesions. Bowen further calls 
attention to the points of similarity between this disease and those of 
acne necrotica, or varioliformis. 

The treatment is unsatisfactory. To prevent recurrences the patient 
should be guarded from exposure to the sun and in some cases from 
hot or cold winds. Veils and covering which exclude the light may 
be of service. Crocker recommends treating the eruption by opening 
the vesicles and applying iodoform in powder or in solution in ether. 
After removing the crusts with carbolized oil he would dress the sur¬ 
faces with an ointment containing iodoform and boric acid. 

A type of eruption similar in appearance, history, and etiology to 
that of hydroa vacciniforme has been described by Unna, Hutchinson, 
Berliner, Graham, and others, under the names of hydroa cestivale , 
hydroa puerorum, and summer prurigo. These eruptions differ from 
those of hydroa vacciniforme chiefly in being more eczematous in 
nature. Itching is commonly present; macules and papules are more 
numerous than the vesicles, which are not umbilicated; and scarring 
is comparatively slight. The disease is found in girls, though less 
frequently than in boys. 


Epidermolysis Bullosa Hereditaria. 

(Acantholysis Bullosa.) 

This name has been given to a rare affection or condition of the skin 
in which there is a pronounced tendency to the rapid formation of bullae 
wherever the integument may be slightly bruised or rubbed. Cases have 
been reported by Goldscheider, Kobner, Valentine, Legg, Elliott, 1 
and others. In the majority of cases reported the condition had 
existed from infancy or early childhood, and there was a clear history 
of heredity. Valentine reported eleven cases which occurred in four 
generations of the same family. 

The general health of individuals thus affected may be excellent and 
the skin remain sound so long as it is subjected to no irritation, but in 
some cases very slight causes (the pressure of a shoe in walking; the 
grasping of a firm substance, such as the handle of a hammer; the 
friction of the suspenders or waistband) are sufficient to cause the 
appearance at the site of the irritation, of firm, tense blebs. Such 
bullae vary in size from that of a small pea to that of a walnut. They 
often last some days, having a firm roof-wall; are usually more or less 

1 Journal of Cutaneous and Genito-Urinary Diseases, January, 1895. 


INFLAMMA T10NS. 


403 


painful, especially after rupture; and finally disappear without leaving 
either pigmentation or scar. The predisposition to the formation of 
new bullae, however, remains indefinitely. 

Valentine, Unna, and Elliott think the condition has been improp¬ 
erly named; that it is in reality a dermatitis of traumatic origin, in 
which the rapid, excessive exudation from the vessels of the corium 
tears apart the rete and forms the characteristic bullae. 

No treatment has yet been found capable of relieving the patient of 
this uncomfortable tendency. 


Hidradenitis Suppurativa. 1 

(Hydradenitis Destruens Suppurativa ; Folliculitis 
Exulcerans.) 

This disorder was described in 1864 by Verneuil, and since then has 
been observed by Dubreuilh, 2 Pollitzer, 3 and others. 

The lesions begin as deep-seated, firm, shot-like, insensitive nodules 
over which the skin is movable and unaffected. Each nodule slowly 
enlarges for a week or more until it attains the size of a pea and 
becomes soft, slightly painful, and attached to the skin, which is then 
reddened. On puncture the lesion gives exit to a drop or two of pus; 
but if left to itself, it becomes yellowish, bursts spontaneously, and 
becomes covered with a dirty adherent crust which soon falls, leaving a 
pigmented spot, and ultimately a slightly depressed scar. 

The most common sites of the disorder are the regions of the axilla, 
anus, nipple, scrotum, and labia majora. In these parts the lesions 
may be single or more numerous. They occur also in large numbers 
over other parts of the body, especially on the face and neck. No 
cases have yet been reported with lesions of the soles. 

Occasionally several nodules coalesce to form a flat tumor with a 
number of openings; or the small, firm lesions of the first stage may 
persist as such for mouths, terminating in absorption. The disease is 
usually chronic in its course, and by a successive lesion or crops of 
lesions may endure for months or for years. 

Etiology and Pathology. As predisposing causes should be counted 
all conditions, general or local, which tend to lower the vitality of the 
tissues. The origin is unknown, though it is probably to be sought 
in local infection or in the action of some toxic agent excreted by the 
coil-glands. 

The process has been shown to be a diffuse inflammation of the coil- 
glands and periglandular tissue, usually terminating in suppuration 
and destruction of the gland. 

Treatment. The general condition of the patient should furnish the 
indications for treatment of each case. Locally the nodules should be 
opened and dressed antiseptically. The disease is stubborn, but event¬ 
ually terminates in recovery. 

1 In the future this affection will be classed with disorders of the coil-glands. 

2 Arch, de Med. exper. et d’Anatomie pathol, 1893, i. 

3 Journal of Cutaneous and Genito-Urinary Diseases, 1892, p. 9. Also, Morrow’s System, vol. 
iii. p. 771. 


404 


DISEASES OF THE SKIN. 


CLASS III. 

HEMORRHAGES. 

CUTANEOUS HEMORRHAGES. 

Cutaneous hemorrhage is characterized by the issue of a part or of all the constitu¬ 
ents of the blood from the cutaneous or the subcutaneous vessels, with and without 
rupture of the vascular walls. 

Hemorrhage into the skin may be active or passive, idiopathic or 
symptomatic, and may vary greatly in extent. It may be limited 
to but a small area of the integument, or may be symmetrical and 
universal, or may coexist with similar blood-extravasations in the 
mucous membranes, and the investments and parenchyma of the viscera. 
It may result from undue intravascular pressure, as in violent effort 
with extraordinary demand upon the circulatory system. It may occur 
with a normal intravascular pressure when there is lessened extra- 
vascular atmospheric pressure, as after ordinary exertion in high alti¬ 
tudes. It may result from disease of the vascular walls (as in malnu¬ 
trition) or it may occur after traumatism of the latter, or by diapedesis 
through the walls of uninjured capillaries. It may result also from 
lack of support of the vessels due to various disorders of perivascular 
tissues, as in the case where the epidermis is artificially removed, or 
where an abscess-cavity is evacuated of pus, and the sac immediately 
fills with blood. 

Idiopathic hemorrhage into the skin and neighboring tissue is usually 
the result of traumatism, and is accomplished through the rent of the 
vascular wall. The discolored patches which result from contusions 
of the surface of the body are illustrations of this condition. Exam¬ 
ples of symptomatic cutaneous hemorrhages are to be found in the 
course of such general disease, as septicemia and variola, and of such 
cutaneous disorders as herpes, pemphigus, and erythema multiforme. 
The visceral complications of some forms of cutaneous hemorrhage 
and of erythema multiforme have carefully been studied by Osier. 1 
He mentions specially gastro-intestinal crises, nephritis, cardiac and 
respiratory disorders. 

Bulla: Hemorrhagica: are globoid, bean- to egg-sized elevations 
of the epidermis, filled with a sanguineous or sero-sanguineous fluid, 
giving such lesions a reddish, brownish, or a purplish shade. 

Ecchymomata are nut- to egg-sized, and even larger, firm or fluct¬ 
uating, flattened or elevated tumors (filled with blood) having a cuta¬ 
neous envelope. 


1 American Journal of the Medical Sciences, December, 1895. 


HEMORRHAGES. 


405 


Eccyhmoses are small coin- to palm-sized, and even larger, light- 
red to dark-purplish, irregularly shaped, macular colorations of the 
skin, not fading under pressure, and are due to circumscribed cutaneous 
hemorrhage. 

Petechia are pin-point- to small coin-sized, light red to dark-pur¬ 
plish macular colorations of the skin, not fading under pressure, and 
are due to circumscribed cutaneous hemorrhage. 

Vibices are linear maculations of various lengths, due to the diffu¬ 
sion in the skin of extravasated blood in the form of streaks or bands. 
They are often commingled with petechise and ecchymoses. 


PURPURA. 

(Gr. TToptyvpeog, purple.) 

Statistical frequency in America, 0 275. 

Purpura is a disease characterized by the appearance in the skin of reddish-purple 
or livid macules (varying in size, usually not clustered, and not wholly disappear¬ 
ing under pressure) which may be associated with systemic symptoms. 


Some confusion has existed in connection with the term Purpura, in 
consequence of the fact that it has indiscriminately been employed by 
authors to designate both symptoms and diseases. The following dis¬ 
orders are commonly included under this title: 


[A] Purpura Simplex. 

Statistical frequency in America, 0.145. 

In this form of cutaneous hemorrhage, pin-head- to pea-sized, light- 
red to dark-purple petechise and small ecchymoses, usually multiple 
and svmmetrical, of slow or of sudden occurrence, appear upon various 
portions of the body-surface, chiefly over the lower extremities, and 
here doubtless by preference, because of the greater effect of gravity 
upon the column of blood. The lesions usually awaken no subjective 
sensation, and they may occur in persons of apparently unaltered 
health, though rigid examination will often disclose some facts haying 
a bearing upon the etiology of the disease. The subjects of the disor¬ 
der are frequently asthenic, and they complain of unwonted lassitude 
and malaise. The disease may last for a fortnight, and in exceptional 
cases may be accompanied by a febrile rise of temperature. Lesions 
of this sort may be due solely to an ingested medicament, such as 
arsenic, salicylic acid (Freudenberg), or quinin. The lower extremi¬ 
ties may be completely covered with petechise, induced by ingestion 
of the iodid of potassium. 


406 


DISEASES OF THE SKIN. 


Purpura Urticans. 

Purpura urticans is that form in which there is an irritability of the 
skin sufficient to produce wheals, urticarial lesions accompanied by 
itching in various degrees, that have the purpuric hue in consequence 
of circumscribed cutaneous hemorrhage. 


[B] Purpura Rheumatica (Peliosis Rheumatica). 

This variety of purpura, which has a striking analogy to erythema 
multiforme, is probably an exaggerated form of some of the conditions 
recognized under that title. It is preceded by the usual febrile or 
other premonitory symptoms associated with arthritic pains, especially 
of the knees and ankles, which may become swollen, or be affected 
with a hydrarthrosis. In a few days, petechial to ecchymotic, light- 
red to dark-purplish maculations appear upon the extremities, the 
trunk, or the entire surface of the body, fadeless under pressure, and 
usually with coincident relief of the arthritic pain. The subjective 
sensations are ordinarily trivial. In a fortnight the eruption may 
subside, its color undergoing the usual variations from greenish to 
orange and light-yellow; but relapses are common in the course of 
weeks, with recrudescence of the fever, return of the rheumatoid symp¬ 
toms, and progressive asthenia. Kaposi describes cases in which there 
was coincidence of purpura rheumatica with renal hemorrhage, albu¬ 
minuria, and gangrene of the soft palate in consequence of its over¬ 
distention with blood. Cases are also on record where there were 
cardiac involvement and grave disorder of other viscera. According 
to Mackenzie , 1 the disease occurs in both sexes, more frequently in 
women however, and between the ages of twenty and thirty, though 
also at earlier periods of life. The purpuric spots observed by him 
usually made their appearance regularly in the afternoon or evening, 
sometimes daily and often with several days’ interval, accompanied 
by pain, stiffness, and swelling of the joints. The macules were at 
first of a bright reddish hue, but became purplish by the ensuing day. 
The site of predilection was the extremities, but the eruption in Mac¬ 
kenzie’s cases was sometimes more generalized. 

The lesions displayed this amount of symmetry: if they occurred 
on one extremity, upper or lower, they would generally be found on 
the other. As a rule, there were no profuse sweats, unless the attack 
occurred with rheumatic fever; the joint-affections and pyrexia, though 
distinct, were not severe. Sometimes there was a certain amount of 
erythema accompanying the hemorrhages ; often the eruption was purely 
hemorrhagic. The attacks were frequently protracted, lasting even 
for months, and they were liable to recur. 

The disease occurs in both sexes, though more often in young women, 
and it is to a certain extent influenced by the changes of climate and 
season. Its diagnosis, in consequence of its marked characteristics, 


1 British Medical Journal, March 18,1882, p. 383. 


HEMORRHAGES. 


407 


coincidence of petechiae and ecchymoses with rheumatoid pains, is 
readily effected. Duhring calls attention to the danger of confound¬ 
ing the disease with the macular syphiloderm, the lesions of which, 
however, fade under pressure. 

The prognosis is in general favorable,, though the disease may persist 
for long periods of time, and may, in rare cases, terminate fatally. 


[C] Purpura Hemorrhagica (Morbus Maculosus Werlhoffii). 

Statistical frequency in America, 0.039. 

This disorder, called also “ Land-scurvy/’ is usually ushered in with 
phenomena of a febrile character, accompanied by symptoms of gen¬ 
eral depression. Subsequently ecchymoses appear upon the extremities 
and the trunk, both spontaneously and at points where the integument 
has specially been subjected to pressure and friction. Often petechiae 
appear simultaneously upon the nasal, laryngeal, buccal, and other 
mucous surfaces, which may also be the seat of exhausting hemorrhages, 
resulting rarely in fatal collapse. A symptomatic fever is usually 
awakened. The disease occurs equally in the robust and the feeble of 
all ages, and, though commonly a sporadic affection, it may assume an 
epidemic form. The disease is slow in its course, but, as a rule, termi¬ 
nates favorably after the lapse of several months. 

The lesions commonly appear first on the upper extremities, then 
over the trunk, and finally over the lower extremities. They are 
usually dark-red or purplish in hue, varying in size from that of a 
pin-head to that of a bean, but they may be of the size of the palm. 

Hemorrhagic purpura is distinguished from purpura scorbutica, or 
u scurvy/’ by the absence of distinctive premonitory symptoms of the 
latter disease, and by its invariable occurrence among those suffering 
from improper alimentation, vitiated air, and lack of exercise. 


[D] Purpura Scorbutica (Scurvy). 

This disorder is peculiar to those who are compelled to subsist for 
lengthened periods of time on improper food, more particularly that 
from which fruit and fresh vegetables are excluded; to respire a viti¬ 
ated air; and to endure such confinement as precludes the possibility 
of duly exercising the body. The disorder is, hence, more common 
among sailors, prisoners, Arctic voyagers, and men similarly situated. 

The cutaneous lesions are, as in so many other forms of purpura, 
preceded by an almost characteristic sense of languor and depression. 
One or several joints may then enlarge. There may, however, be 
a distinct febrile action. 

The hemorrhages which result are quite like those of purpura hem¬ 
orrhagica; the cutaneous lesions are petechise, ecchymoses, and painful 
ecchymomata, usually first appearing on the lower extremities, that 
may fluctuate, open, and result in offensive ulcerations reaching to the 


408 


DISEASES OF THE SKIN. 


bone. Simultaneously with the cutaneous eruptions the gums become 
involved, showing as tumid, hemorrhagic, or ulcerative fungosities, 
smeared with a dirty yellowish secretion, and having a fetid exhalation. 
The subcutaneous connective tissue, muscles, fasciae, and viscera become 
involved. The disease is accompanied by febrile and other general 
phenomena of asthenia, and, when the causes are persistent, results 
fatally. It is, however, remediable by proper treatment, though con¬ 
valescence is usually tediously prolonged. 


[B] Purpura Pulicosa. 

Purpura pulicosa is the result of the traumatisms produced by fleas, 
lice, and bugs. The lesions are punctiform, and are due to the welling 
up of blood into the minute punctured wound, which is surrounded 
usually by a hyperemic halo, the result of the irritation. When the 
areola fades the central hemorrhagic point usually persists for a brief 
time. The disease is characteristically manifested upon the filthy skins 
of individuals long bitten by bugs, and covered with excoriations and 
dark-colored crusts, the result of scratching. Such cases are often 
pronounced scorbutic. 

The symptoms of cutaneous hemorrhage are observed in other con¬ 
ditions beside those named above. Petechise and ecchymoses are also 
displayed upon the lower extremities of some of the subjects of tuber¬ 
culosis, of cancer, and of the plague. In Hemophilia, a disease 
occasionally of hereditary origin, and characterized by the facility with 
which trivial traumatisms of the body-surface are followed by incoer- 
cible hemorrhages, purpura may be the first signal of the predisposi¬ 
tion. A young man with purpuric lesions of both lower extremities, 
but otherwise apparently in good health, lately presented himself at 
the Dermatological Clinic for the relief of the difficulty. There was 
at the time no suspicion of hemophilia, but two weeks later, as the 
result of a vaccination, he bled continuously for eight days. 


General Considerations Respecting the Purpuras. 

The symptoms described under separate titles are, in fact, merely 
surface-symptoms of different local and systemic states. Various 
classifications have been made of them, the best of which are based 
upon analogy with demonstrated facts in similar morbid conditions. 

1. Primary infectious purpura. Letzerich, in 1889, recognized in 
the spots of purpura hemorrhagica long bacilli, cultures from which 
injected into rabbits produced a species of bacillogenous purpura with 
stuffing of the hepatic capillaries by colonies of the same micro¬ 
organism. The belief is at present gaining ground that purpura scor¬ 
butica and other forms of purpura are infectious disorders, the micro¬ 
organisms of which have not yet been identified and demonstrated as 
effective agents in the production of the disease. 


HEMORRHAGES. 


409 


2. Secondary infectious purpura. In this group should be arranged 
the lesions exhibited in hemorrhagic variola (*•' black measles”), snake¬ 
bites, typhoid fever, and other diseases of recognized infective origin. 

3. Purpura symptomatic of general non-infective disorders. In this 
group may be included the lesions produced by drug-ingestion, anemia, 
leukemia, and cachexia. 

4. Purpura due to local causes. Here may be classed the lesions 
due to fragments of sarcomata lodged in the vessels of the part affected 
(Fagge); to incursions of lice, bugs, etc.; and to changes in the vascular 
walls due to metamorphosis of the cellular elements. 


Etiology and Pathology. Many instances of purpura are either 
primary or secondary results of an infective process due to bacillo- 
genous products. The results of the investigation of this subject made 
by Letzerich, Petrone, Guimard, and others have already been referred 
to. It is probable that in other forms of purpura facts of similar 
etiological importance will be established. 

Many cutaneous hemorrhages, not resulting from traumatism, how¬ 
ever manifestly and immediately due to morbid conditions of the ves¬ 
sels, are by many authors believed to have a neurotic origin. Purpura 
hemorrhagica, for example, in consequence of the frequent absence of 
lesions of the vascular walls sufficient to produce its phenomena, is by 
Wagner, Henoch, and others explained by supposing either abnormal 
excitation of the sympathetic system, or paresis of the vaso-motor 
centres. Cavalier 1 reports a case of purpura alternating with paralytic 
symptoms. The frequently symmetrical disposition of the lesions has 
received a similar interpretation. Tyrrell 2 reports cases induced by 
marsh-miasm, and Satterthwaite, 3 of New York, a similar case, in 
which the eruption followed a chill lasting three-quarters of an hour. 

In all these cases the hemorrhages occur chiefly in the derma, though 
often in the subcutaneous connective tissue, a fact well illustrated by 
the drawings made by Variot 4 of sections of the purpuric skin of a 
patient dead of hemoptysis. In this case there was numerical diminu¬ 
tion of the red corpuscles in life (as demonstrated by the hematimetre) 
without any change in their form, volume, or color. Inflammatory 
complications in these conditions are rare. The color of the several 
lesions induced is derived, without question, from the he matin, which 
not only stains the environing fluids, but also the tissues themselves 
where the extravasation occurs, and appears, when absorption of the 
fluid portions of the clot has been accomplished, in the form of vari¬ 
ously sized granules. In this way the color-changes between red, 
orange, yellow, purple, and violet in the resolution of petechise and 
ecchymoses are to be explained. The persistence of the pigmentations 
varies with the quantity of the effused blood and its seat. In mild 
cases, especially of lesions involving the upper half of the body, all 
traces of the hemorrhage may be removed in the course of a few weeks. 
Hark pigmentation resulting from purpura scorbutica is, in some 


1 Bull. g6n. de Th6rap., 1879. 2 Pacific Medical and Surgical Journal, June, 1876. 

3 Medical Gazette, January 14,1882, p. 14, cited by Duhring. 

4 Journ. de l’Anatom. et de la Phys., November, December, 1881, p. 520. 


410 


DISEASES OF THE SKIN. 


persons, perceptible upon the lower extremities after years of persist¬ 
ence. 

Wilson, Fox, and others, again, have recognized lardaceous or 
inflammatory changes in the vascular walls, with embolism or thrombus 
in others. Watson Cheyne 1 discovered, in a case recorded by Russell, 
some of the capillaries in the neighborhood of the hemorrhages plugged 
with bacilli, and colonies of the same in the blood effused after rupture. 

Treatment. The treatment of these various forms of cutaneous hem¬ 
orrhage will clearly depend upon the nature of the cause in each case. 
In general it may be said that internally the use of ergot, of the 
chlorid or other salt of iron, and of quinin is advisable. Oil of 
turpentine, tincture of the muriate of iron, acetate of lead, and dilute 
sulphuric acid have all been employed at times with marked success, 
at others without avail, in the treatment of these cases. Hypoder¬ 
matic injections of Bonjearns ergotin, one part to two of distilled 
water, repeated every second day, have speedily been followed by 
favorable results. A generous diet, the use of wines, malt liquors, 
and even spirits, and strict observance of the demands of hygiene, are 
often essential methods of relief. 

In the way of local treatment the gums often require an application 
of rhatany, one part of the extract to fifty or sixty of lotion; or 
equal parts of tincture of cinchona and tincture of myrrh, diluted as 
required. 

Rest in the recumbent position is advisable, and, if hemorrhage be 
actually in progress, the free use of hemostatics will be required with 
local application of ice. For those who are convalescent from systemic 
disorders accompanied by purpuric lesions of the lower extremities, 
resorption of the extravasated blood may be hastened by the local appli¬ 
cation of stimulating spirit-lotions with friction; and the pressure of 
the blood-column may partly be relieved by elastic bandaging of the 
extremities. 

The prognosis has been given, as far as might be, in connection with 
each disorder named. 


1 British Medical Journal, September 1,1883, p. 416. 


HYPER TR OPHIES. 


411 


CLASS IV. 

HYPERTROPHIES. 

1. HYPERTROPHIES OP PIGMENT. 

LENTIGO. 

(Lat. lens, a freckle.) 

(Freckles, Ephelis. Ger ., Sommersprosse.) 

Lentigo is that condition in which occur pin-head to bean-sized, yellowish to brown¬ 
ish, circumscribed, and usually multiple maculations of the cutaneous surface, due 
to an excessive deposit of pigment, most often seen on the face and dorsal surfaces 
of the hands. 

[ Symptoms. This condition is due to excessive and irregular deposit 
of pigment in the skin, producing the pin-head- to bean-sized spots of 
circinate or of irregular outline, frequently grouped and even confluent, 
which spots are commonly designated as u freckles.” They are most 
frequently seen symmetrically distributed on those parts of the body 
ordinarily exposed to the light and heat of the sun and to atmospheric 
influences, such as the face, the neck, and the backs of the hands in 
persons of both sexes. In those individuals whose bodies are to a 
greater extent similarly exposed they occur upon the chest, the back, 
and over the extremities. In other persons they may be seen upon 
parts not thus exposed, such as the penis, the scrotum, and the inner 
faces of the thighs, a fact which indicates that freckles are not 
always the result of the operation of the agencies noted above. They 
vary in color from light yellow, salmon, or red to the deepest brown; 
and are most noticeable in those having red hair and a delicate skin. 
Freckles occur rarely in infancy, partly, perhaps, on account of the in¬ 
frequency of outdoor exposure in tender years. They are usually seen 
first about the age of six to eight years. They are commonly observed 
in mulattoes, individuals of a race particularly disposed to the anom¬ 
alies of pigment-distribution. Once developed, the lesions may persist 
through life without marked alteration; or may fade with each recur¬ 
rence of the season of winter; or in milder cases may entirely disap¬ 
pear. They usually share in the atrophic changes of old age, and, 
when persisting to that period, may then spontaneously disappear. 
They are not the source of subjective sensation. 

Etiology. Freckles are unquestionably produced and aggravated at 
times by the action of the light and heat of the sun, as common expe¬ 
rience declares; but it is evident that these forces must act upon a 
susceptible skim Of a hundred sailors exposed in precisely similar 
situations on a long cruise, some of the number will uniformly be 
“ tanned,” and other deeply “ freckled .’ 9 Attention has been called 


412 


DISEASES OF THE SKIN. 


to the occasional occurrence of lentigo in the protected parts of the 
skin. White, of Boston, in an interesting paper on melanoderma, 1 
calls attention to the fact that exposure to sea-air and fog, with obscura¬ 
tion of the sun, is sufficient to produce the result. 

Pathology. Freckles are due to an increased deposit of pigment in 
definite areas of the rete mucosum of the epidermis, never in the 
corium. Lesser urges, with strong probability in his favor, that there 
is always a congenital predisposition to these pigment-formations that 
requires certain external conditions for development. 

Treatment. The treatment of lentigines is that of chloasma and 
other pigmentations of the surface. Wertheim, of Vienna, advises: 


R. —Hydrarg. ammon. muriat., gr. lvj ; 

Bismuth, magister., gr. lij ; 

Ungt. glycerini, I j ; 

Sig.—To be applied only every other night. 

Bulkley employs: 


M. 


R.—Hydrarg. chlor corros., gr. vj; |4 

Acid, acetic, dilut, f % ij ; 8 

Boracis, ^ij; 2 66 

Aq. ros , f^iv; 128| M. 

Sig.—To be applied night and morning, at first with gentle brushing; after¬ 
ward by rubbing. 


Hardaway touches each freckle with a rather stiff needle connected 
with the negative pole of a galvanic battery, and he finds the results 
satisfactory. 

Most of the secret methods employed by charlatans for the removal 
of freckles depend for their success upon thorough blistering of the 
surface. Inasmuch as by this process the epidermis is removed, it is 
evident that the pigment of its cells is also removed with it, and the 
new epidermis is for a time quite free from blemish. But in all such 
cases the ultimate result is a deeper and more persistent pigmentation 
than that which was previously visible. 


CHLOASMA. 

(Gr. to possess a greenish color.) 

Chloasma is that condition in which occur yellowish to blackish, finger-nail- to 
palm-sized, circumscribed, diffuse, and ill-defined maculations of the cutaneous 
surface, due to an excessive deposit of pigment. 

Symptoms. In this affection the skin is either diffusely discolored 
in various shades, or the maculations occur in patches larger than 
those of lentigo, fairly well-defined, and irregular in contour, the so- 
called “ liver-spots.” In color they vary from a scarcely perceptible 
staining of the skin that requires a strong light for its detection, to a 
deep yellow, a yellowish-green, a chocolate-brown, or a blackish shade 
(Melanoderma). They may be either idiopathic or symptomatic in 
character. 


1 Boston Medical and Surgical Journal, May 16,1878, p. 624. 



HYPER TR OPHIES. 


413 


The idiopathic varieties of chloasma are produced by all externally 
operating agencies, in consequence of which an undue afflux of blood 
is persistently determined to any portion of the skin. It is largely 
from the blood that the pigment is derived, hence the stains produced 
by the pigment are, to a certain extent at least, proportioned to the 
hyperemia, stasis, or extravasation of the vascular fluid. Among these 
externally operating agencies may be named pressure and friction (as 
over the part covered by the pad of a truss); traumatism (as after the 
severe scratching of the skin affected with lice, eczema, or scabies); 
heat (as in diffuse “tanning” of the face, or “sunburn” following 
exposure to the solar rays); and the toxic or irritating effect of exter¬ 
nally applied substances, such as mustard, capsicum, cantharides, and 
other articles capable of producing either vesication or pustulation of 
the skin-surface. The physician should always remember the possi¬ 
bility of producing long, persistent, or even permanent pigmentation of 
the skin upon the face, shoulders, and bosom, especially of young 
women, by the repeated application of such topical medicaments. 

The symptomatic varieties of chloasma are the result of disorders 
either systemic or those involving the internal organs. They occur as 
either circumscribed or diffused, localized or generalized, spots, mot- 
tlings, stainings, or “ masks” of the skin, and they vary in color from 
the lightest to the darkest shades. One of the most common, and at 
the same time the most marked of these varieties, is 


Chloasma Uterinum, 

so called because of its frequent association with certain physiol Dgical 
or pathological conditions of the uterus, both among married and single 
women. Thus, in pregnancy, sterility, hysteria, chlorosis, ovarian 
disorders and tumors, and functional derangements of the uterus, there 
can be observed at times a facial discoloration extending equably over 
the forehead aud reaching nearly to the line of the hairs at the scalp, 
in the form of a faint or a decidedly reddish-yellow, or deep-brownish 
tinge. At other times the discoloration is macular and asymmetrical, 
involving the eyelids, the cheeks, the lips, or the chin. When the 
chloasma assumes the mask-like form, it is usually most pronounced 
over the forehead, but it may involve the whole facial region, being 
less distinctly defined below than above. Similarly, the well-known 
changes occur in the areola of the nipple, along the linea alba, and 
about the external genitalia. 


Melanoderma (or Chloasma) Cachecticorum 

is another of the symptomatic pigment-disorders, characterized by the 
changes in the color of the integument of the subjects of tuberculosis, 
syphilis, cancer, chronic alcoholism, malaria (e. g., “ Chagres fever”), 
and other disorders. 


414 


DISEASES OF THE SKIN. 


Addison’s Disease, 

formerly thought to be due exclusively to lesion of the suprarenal 
capsules, is of the same nature, and is characterized by a peculiar 
bronzing of the skin. Overbeck and Greenhow have shown that the 
capsules may completely be destroyed without changes in the skin- 
color resulting. The pigmentation may be general or be partial, and m 
the latter case is without definite lines of demarcation. It is com¬ 
monly most pronounced over the face and neck, the scrotum, the 
groins, the axillae, and the nipple and areola. The hairs become coarse 
and dark: and dark patches are at times visible over the mucous sur¬ 
face of the lips, the gums, and other parts of the mouth. The bronze 
or mulatto-like color of the skin is intensified by stimulation or erosion 
of the cutaneous surface. In these cases there are generally marked 
asthenia and a feeble pulse, with anorexia and other signs of gastro¬ 
intestinal disorder. When the result is fatal there may or may not 
be recognized pathological alterations of the suprarenal capsules. 

Hadra, of Berlin, reports a case of Addison’s disease cured by 
extirpation of a small apple-sized tuberculous neoplasm of the retro¬ 
peritoneal glands. A suprarenal capsule was contained in the growth. 

Among the cutaneous disorders capable of producing skin-pigmen¬ 
tation may be named scleroderma, lepra, angioma pigmentosum et atro- 
phicum, eczema (especially e. venis varicosis ), and general exfoliative 
dermatitis. 

From all the above-named discolorations, which are due solely to 
deposition in excess of coloring-matters normally existing in the skin, 
it is necessary to distinguish the various dyschromia? which are owing 
to the introduction into the integument of coloring-substances, either 
supplied by other portions of the body or entirely foreign to it. Thus, 
in icterus the bile may color the skin from a light yellow to a dark 
chrome shade, the duration and severity of the cutaneous symptoms 
depending upon the nature and gravity of the hepatic disease. This 
condition is frequently accompanied by pruritus in various grades of 
severity, the exact causes of which are obscure. 


Argyria. 

Here a bluish, bluish-gray, slate-colored, or bronzed coloration of 
the skin results from the introduction from without of the nitrate of 
silver. Argyria is most commonly the result of the administration of 
the drug in the treatment of epilepsy, but it is said to have also resulted 
from the topical application of silver crayons to the throat, to the 
conjunctive, and even to the skin. Under what form the silver pro¬ 
duces this effect, whether as an albuminate or other salt, is not known. 
The deposition, however, occurs in the form of minute particles of the 
metal in the connective tissue of the derma. The discolorations are 


i Medical Week, Paris, Oct. 1896. 


HYPER TR OPHIES. 


415 


most evident upon the parts of the skin exposed to the light, as the face 
and hands; but the chest and the lower extremities may be similarly 
stained. The connective tissue of the viscera is at times also involved, 
showing thus that the action of light is not essential to the production 
of the dyschromia. Two cases are reported as relieved by the admin¬ 
istration of the iodid of potassium. 


Anomalous Discoloration of the Skin and the Mucous 
Membranes. 

Bruce 1 describes the case of a harness-maker, the general surface of 
whose body, especially the skin of the face and of the extremities, as 
well as the mucous surfaces, underwent a noteworthy change of color. 
The hue acquired was a deep and uniform cyanotic color. Hutchin¬ 
son believes the color in this case to have resulted from the employ¬ 
ment of nitrate of silver. 


Chloasma from Ingestion of Arsenic. 

The administration of arsenic in full doses for relief of nervous dis¬ 
orders in children has been followed by a characteristic dull-brownish or 
dirty-colored discoloration of the skin of the neck and chest. Cases of 
this sort are not infrequently presented for observation in the clinic. 

Tattooing. 

By the process of tattooing, mineral and vegetable substances are 
directly introduced into the corium by means of needles, for the pro¬ 
duction in the skin of various devices in colors. Individuals whose 
entire integument has been thus artificially covered with figures of 
different patterns by tattooing with indigo, vermilion, and cinnabar 
are from time to time publicly exhibited. The results are indelible. 
Post mortem these pigments have been discovered not only in the 
derma, but also in the lymphatic ganglia nearest the site of their in¬ 
troduction. 

Pathology . The lentigines, ephelides, and chloasmata are all due to 
excessive deposit of the natural pigment of the body in the rete muco- 
sum of the epidermis. Restoration of the normal color of the skin is 
usually proportioned to the extent and depth of the deposit, but the 
process is always very gradual. It can well be studied in the slow 
bleaching of the pigmentation of syphilitic cicatrices upon the lower 
extremities. In the dyschromias due to the introduction of coloring- 
matters foreign to the body or foreign to the skin the corium and the 
subcutaneous connective tissue are commonly stained. 

Diagnosis. The diagnosis of cutaneous pigment-hypertrophies 
is readily effected by observing the persistence of the discoloration 


1 Intern. Atlas of Rare Skin Diseases, 1892, vol. vi. 2, 7. 


416 


DISEASES OF THE SKIN. 


under pressure; the absence of all symptoms of hyperemia, inflamma¬ 
tion, and secondary changes in the skin, as also by the characteristic 
shades of color presented to the eye. In tinea versicolor there is 
usually slight furfuraceous desquamation, and the existence of a vege¬ 
table parasite is readily demonstrated by the microscope. The rare 
pigmentary syphilide is usually seen upon the neck and shoulders of 
infected women in the form of yellowish to brownish maculations, 
often arranged in an irregular network. The lesion is, indeed, one of 
the symptomatic chloasmata. 

Treatment. In all the symptomatic pigment-anomalies the indica¬ 
tions for treatment are presented by the disease which begets the cuta¬ 
neous disorder. 

The local treatment of both the idiopathic and symptomatic varieties 
of the affection demands the use of external applications which will 
hasten the physiological reproduction of the epidermis, substituting 
thus new and unpigmented for old and pigmented epithelia. This 
process must also be accomplished without the artificial production of 
such a hyperemia as will tend to add to the very coloration which it 
is attempted to relieve. The substances used for the slow accomplish¬ 
ment of this end are borax, sulphur, tincture of iodin, potash, and 
soda (including the soaps of these alkalies), and the mercurials. None 
of these substances is more generally employed than corrosive sublimate, 
which constitutes the basis of most of the cosmetic lotions sold in the 
shops. 

The following formulae are given by White 1 for use in the evening. 
The preparation in each case should be left upon the affected surface 
during the night, and be removed by a soap-and-water washing in the 
morning. They are to be used for weeks in succession, but only after 
a cautious preliminary testing of the sensitiveness of the skin to their 
action. To avoid the possibility of error, the practitioner would do 
well to order a poison-label upon all vials containing the sublimate: 


B-—Hydrarg. am. chlor., \ 
Bismuth, magister., J 
Amyl., 1 
Glycerin , J 

B-—Ammon, muriat., 

Aq. Colognien., 

Aq. 

B.—Hydrarg. bichlorid., 
Acid. mur. dil., 
Glycerin., 

Alcoholis, \ 

Aq. ros., J 
Aq. duct., 


aa 3 ij; 

8 

aa gss; 

16 

3ss; 

2 

f^j; 

32 

Oss; 

256 

gr- vj ; 

f 3 j; 

4 


32 

aa f% ij; 

64 


128 


The following formulae for ointments are given by Kaposi: 


B.—Hydrarg. ammon., 
Sodse biborat., 

01. rosmarin., 
Unguent, simpl., 


aa £ss; 
gtts. x; 

3j; 


M. 






HYPER TR OPHIES. 


417 


R.—Acid. borac.,'\ 

Cerse alb., J 
Paraffin., 

01. amygd. dulc., 

Van Harlingen recommends: 

R.—Hydrarg. chlor. corros., 

Zinci sulphatis, \ 

Plumbi subacetat., / 

Aq. dest., 

Sig.—Lotion, for external use, morning and evening. 

Other preparations advised are: stimulation with alcohol, and appli¬ 
cation, for several hours after, of a plaster of ammoniated mercury; 
two parts of magnesium carbonate and zinc oxid, four of pure kaolin 
and glycerin, and ten of vaselin; chloroform, one hundred parts, chrys- 
arobin, fifteen parts (Leloir); peroxid of hydrogen; diluted acetic, 
carbolic, muriatic, and nitric acids; one to two parts of salicylic acid, 
in paste or powder, to twenty parts of base; and solutions of mercuric 
bichlorid in collodion, one part to thirty, employed with great caution. 

The rapid removal of pigmented patches is accomplished, in Vienna, 
by covering the part with strips of linen dipped in an aqueous or an 
alcoholic solution of corrosive sublimate of the strength of 4 grains 
(0.26) to the ounce (32.), with which solution the dressing is also occa¬ 
sionally moistened. Vesiculation is usually accomplished in about 
four hours, when the serum is evacuated by puncture, and the detached 
epidermis is covered with any inert dusting-powder. The resulting 
crusts fall in about eight days. The procedure is attended with danger 
of producing, in the end, the precise deformity which it seeks to remedy, 
a danger explained above. 

Another method of removing tattoo-marks and pigmented nsevi, 
successfully employed by French dermatologists, consists in tattooing 
the region, previously rendered aseptic, with a solution of thirty parts 
of zinc chlorid to forty parts of water. If properly done, the resulting 
inflammation is slight, and after a few days there forms a superficial 
crust which remains about a week aud then falls, leaving a slight scar 
which becomes almost imperceptible. This method calls for skill and 
care in its application in order to obtain good results and to avoid sup¬ 
puration and deep cicatrization. 

The internal administration of the iodidof potassium, recommended 
for the removal of argyria, has in the author’s hands failed of any 
good results. Yandell’s two patients, one completely and the other 
partially relieved, were both syphilitic. 

Prognosis. The prognosis is in all cases uncertain. There is strong 
reason to believe that the local treatment of all these dyschromias is, 
in the long run, ineffective. Those methods which effectually and 
brilliantly accomplish the desired end are almost invariably followed 
by deeper pigmentation than that which it was attempted to remove; 
those operating more slowly have, probably, a less speedy, but scarcely 
more disguised sequel. It is likely that local treatment of these pig¬ 
mented states will ere long be abandoned as inadvisable. The treatment 
intelligently directed to the cause of each discoloration is that which 
in the end proves most satisfactory. 


aa 3j; 
5j; 


gr. vss; 
aa i^ss; 


M. 


2 

128 


M. 




418 


DISEASES OF THE SKIN. 


2. HYPERTROPHIES OF EPIDERMAL AND PAPILLARY 

LAYERS. 

KERATOSIS. 

(Gr. Kipac, a horn ) 

The term Keratosis was first applied by Lebert to hypertrophic lesions 
of the epidermis. It has since been made to include changes in both 
the epidermis and the corium, and it is employed by some authors in 
a generic sense to embrace a number of both localized and general 
hypertrophies of these portions of the skin. 


[A] Keratosis Pilaris. 

(Lichex Pilaris, Pityriasis Pilaris.) 

Keratosis pilaris is a disorder, chiefly of the extremities, characterized by multiple, 
millet-seed-sized, whitish, grayish, or slightly reddish aggregations of epithelium, 
about the orifices of the hair-follicles. 

Symptoms. This condition may be a mere temporary functional dis¬ 
turbance of the skin, awakening no subjective sensation, inappreciable 
by the patient, and apparent only to the careful observer, or it may 
really constitute a disease. Its symptoms are the occurrence of pin- 
head-sized, pointed elevations of the skin-surface, that may be described 
as papules, though, strictly speaking, they are not such, but are con¬ 
stituted by an accumulation of horny epithelia and a small quantity of 
inspissated sebum about the lanugo-hairs of the extensor surfaces of the 
extremities and trunk. These aggregations of material are usually 
of a dirty-whitish or grayish hue, and are pierced by a lanugo-hair 
implanted in the follicle about which the abnormal condition exists. 
Occasionally, however, the hairs are of the finer and shorter kind, 
and are often coiled in or otherwise covered by the little heaps of 
epithelial debris. The skin of the individual thus affected is generally 
harsh, squamous, and dry to the touch; being also, in the majority of 
cases, long unwashed. The color of the quasi-papules differs also with 
the complexion of the individual; at times the papules have a dis¬ 
tinctly reddish tinge, and they are often surmounted by a scale. 

Keratosis pilaris is sufficiently common in skins long uncleansed by 
ablution, and this condition can thus artificially be produced. In 
some individuals it persists for long periods of time, and awakens no 
concern. In others, especially in children, it speedily becomes the 
source of pruritus, and each lichenoid papule may then be transformed 
into an urticarial wheal, with distinct and sometimes very annoying 
pricking and tingling sensations, the entire trouble being at once 
relieved by a bath in warm water with soap. In still other individuals, 
especially in adults, an exaggerated form of the disease can be recog¬ 
nized, the skin presenting a roughness to the touch suggestive of the 


HYPER TR OPHIES. 


419 


surface of a nutmeg-grater, and exhibiting numerous fine, conical, 
grayish, horn-tipped filaments, which several dermatologists are dis¬ 
posed to regard as a form of ichthyosis. In the latter case there is 
doubtless a true hypertrophy of the epidermis. In the former case, 
there is scarcely more than a mechanical accumulation of effete organic 
material. There can be little doubt that the malady, simple though 
it be in character at the onset, may become the first stage of a series of 
chronic cutaneous disorders. Tilbury Fox has reported four cases in 
which the disease was well marked, under the title Cacotrophia 
Folliculorum, this name being employed to designate its peculiari¬ 
ties as to wide distribution over the body, its implication of the deeper 
portion of the follicles, and its congenital history. In these cases the 
reddish tint of the lesions is distinctly shown. 

Brocq, who devotes an extensive chapter to this affection, describes 
four forms: ( a ) a white variety, the uncolored circumpilarv papules 
being scattered over the arms, forearms, legs, and thighs, usually on 
the outer faces of the extremities; (6) a mild form, in which some 
reddish papules are disseminated among those of the “white” class; 
(c) a form of medium intensity, where the papules are generally rosy- 
red in hue; (d) an intense form, where well-marked lesions occur over 
the surface of the chest, the lumbar and pubic regions, and the folds 
of the larger articulations. 

Keratosis pilaris on the face, as described by French writers, is char¬ 
acterized by exceedingly minute, usually conical, occasionally obtuse 
papules (each pierced by a fine hair) that develop over the brow, about 
the eyebrows, over the cheeks and the inframaxillary region. 

Keratosis of this type can scarcely be described as a a morbid 
state. Even when most numerous and vividly red the lesions are 
wholly destitute of inflammatory symptoms, and the subjective sensa¬ 
tions they induce, as a rule, are insignificant; the persons who complain 
at all in these matters being usually those exceedingly anxious to be 
rid of the disorder. These patients are readily divided into two 
classes: first, comely young women desiring to exhibit bare arms in 
evening toilet; second, young men suffering from the delusion that 
they are victims of a “ disease of the blood” or of syphilis. Viewed 
as a whole, the subjects of the best types of this so-called “ disease” 
are men and women of exceeding vigor, with firm, well-developed 
muscles and shapely limbs. 

Pathology. Keratosis pilaris is produced by the accumulation of the 
cells of the horny layer of the epidermis and sebaceous material about 
the orifices of the hair-follicles. In some cases the result is an irritation 
which produces a more or less persistent hyperemia of the perigland¬ 
ular tissue. 

Etiology. Puberty and uncleanliness have been assigned as causes of 
the disorder; both conditions may in some patients be indirectly effec¬ 
tive. In some individuals the condition seems to follow a prolonged 
course of arsenic. A careful study of a group of exaggerated cases occur¬ 
ring in adult men and women, however, suggests more essential reasons 
for the disease. In such exceptional cases the outer faces of the 
limbs, and even the entire belly may be covered with faintly pinkish 


420 


DISEASES OF THE SKIN. 


or bright-reddish firm papules, many of them scale-capped, all seated 
at the orifice of a hair-follicle. In these patients there may be a 
history of regular ablution and persistence of the malady long after 
puberty; but in general they will be seen to have peculiarly thick, 
coarse, usually dark-colored skins, and also to be persons of marked 
muscular vigor and unusual development of most of the other bodily 
tissues. In brief, the disorder seems to be due often to marked inher¬ 
ited predisposition in persons of vigorous constitution. The varieties 
of keratosis pilaris seen in cachectic hospital patients, and in persons 
who have aggravated the disease by inducing a medicamentous rash 
upon the person, belong to a different category. Patients in the last- 
named two classes may be so perfectly relieved that there is no predis¬ 
position to a return of the disorder, a relief not always to be secured 
by the others. 

Diagnosis. The disease should readily be recognized by the peculi¬ 
arities of its seat, its course, and the nature of its symptoms. From 
ichthyosis it can be distinguished by the limitation of its lesions to the 
orifice of the hair-follicle; from the transitory condition known as 
u goose-flesh” by its persistence after the surface of the skin is thor¬ 
oughly warmed; from papular eczema and the other lichenoid erup¬ 
tions by the relatively insignificant character of the lesions, their 
evident association with follicular inertia, and the entire absence of 
inflammatory symptoms. 

The disease is to be carefully differentiated from pityriasis rubra 
pilaris, in which the characteristic disorder of the scalp, the appear¬ 
ance of plaques of disease covered with fine pityriasic scales (often 
upon the tip of the nose and chin, exhibiting a peculiarly dark, smirched 
appearance), the affection of the nails, and the evident admixture of 
the disease with some symptoms of seborrhoic type, suffice to determine 
its nature. 

It is a matter of very considerable importance to distinguish keratosis 
pilaris from papular syphilodermata, since many male patients have for 
years swallowed medicaments for relief of a supposed syphilis whose 
sole u symptom” is a keratosis pilaris. But the papular syphiloder¬ 
mata are not persistent year after year, are not throughout symmetrical, 
and are not limited largely to the outer faces of the limbs, especially 
of the thighs. They are preceded by a history of infection and inva¬ 
riably are accompanied by some other manifestations of the disease. 
They are not limited to the orifices of the hair-follicles, and are not 
capped by the peculiar horny scaling tip of the papule of keratosis 
pilaris. 

Crocker describes a lichen pilaris which he considers distinct from 
keratosis pilaris, as in the former the follicular elevations are more 
pronounced and resemble spines, there is usually evidence of inflamma¬ 
tion, and the eruption tends to occur in patches instead of being diffuse. 

Treatment. For the subjects of this disorder in its typical forms it 
is not sufficient merely to order a bath. The bathing should be con¬ 
ducted systematically for years at a time. 

As soon as it can well be tolerated, the patient should be urged to 
bathe the entire surface of the body every morning by the use of the 


HYPER TR OPHIES. 


421 


sponge and cold fresh or salt water, following this with brisk friction 
by the aid of a coarse towel or a flesh-brush. The habitual use of this 
cold bath continued daily for years, in persons who can tolerate it (and 
patients affected with keratosis pilaris are usually of this class), accom¬ 
plishes results of the most satisfactory character, exerting, as it does, 
a profound influence on the nutrition and healthfulness of the skin. 

For immediate treatment of the most of these cases, however, the 
hot bath with soap is desirable. This bath may be repeated as often 
as required to remove the lesions, and be followed, in the more urgent 
cases, by inunction, with the fats or oils. In the congenital and severe 
types, such as those described by Fox, cod-liver oil, internally, should 
be ordered. 


[B] Keratosis Senilis. 

Senile changes in the skin are commonly of the character of those 
studied by Neumann, in which granular opacities appear in rows in the 
corium, giving it a dull greenish-yellow or saffron-colored hue. Later, 
the fibrillse of the corium are almost entirely replaced by finely granu¬ 
lar masses, the remaining fibres becoming swollen and gelatiniform, 
reverting thus to an embryonic type. 

Side by side with these degenerative changes, but also without them, 
the skin of the aged may become harsh, dry, and unusually cornified 
either diffusely or in certain definite regions, such as the hands, 
feet, or extremities; this may be regarded as the simplest form of 
keratosis senilis. The skin of the entire body, or of the region 
affected, is then dark in color, dry to the touch, occasionally covered 
with fine, rather adherent scales, representing merely attached and 
cornified cells of the horny layer of epidermis, and notably unprovided 
with the natural unguent of the skin. 

In a more advanced grade the skin undergoes changes closely allied 
to epithelioma; often, indeed, these both furnish the first symptoms of 
epithelioma and coexist with its gravest destructive effects. The skin 
more commonly of the face, the hands, or the forearms, less often of 
the feet, the legs, and the genital regions of the aged, is covered with 
thin, horny, often greasy-looking, pin-head- to nail-sized aud larger, 
dark-yellowish plates or scales, between which the integument that has 
undergone the atrophic changes in the senile skin is visible. Pig¬ 
mented puncta and macules may also appear, scattered irregularly over 
the surface, with rough, dirty-yellowish to dark-brownish, granular 
accumulations upon the skin of certain regions, such as the clefts beside 
the alse of the nose, the temples, etc. The appearance is quite sugges¬ 
tive, in some cases, of a seborrhea sicca of the face. In many patients 
exhibiting these features a fully developed papillomatous, superficial, 
or deep epithelioma may be present. In other patients one or more 
varieties of the senile wart may be visible, as described in the chapter 
on Verruca. 

Viewing this subject of senile keratosis in the light of the knowledge 
had upon the subject to-day, it must be admitted that the boundary-lines 
between it and epithelioma are not well established. Unquestionably 


422 


DISEASES OF THE SKIN. 


the exaggerated lesions of the former affection are frequently the first 
stages of the latter disease, and in the treatment of the skin of the 
aged, conducted on the general principles already set forth, the physi¬ 
cian should never lose sight of possibly serious consequences in one or 
more regions of the skin affected. 


[C] Keratosis Follicularis. 

(Psorospermosis, Psorospermose foletculaire v£getante, 
Ichthyosis follicularis, Acne s£bac£e cornee, Darier’s 
Disease.) 

In 1889 Darier 1 and Thibault, in France; White, in America; 
and, later, Wickham, 2 Neisser, and others, called attention to a cuta¬ 
neous disorder not previously distinguishable from other maladies. 
About twenty cases have been recorded. In a recent paper 3 reporting a 
new case Bowen gives a brief summary of the clinical and patholog¬ 
ical characteristics of the disease as described by other observers. 
The eruption displayed was practically generalized in the few cases 
reported, and was exhibited in greatest abundance over the limbs, the 
front of the chest, the inguinal and genital regions, the scalp, the face, 
and the loins. The first lesions were firm, pin-head-sized papules, 
scarcely different in color from that of the surrounding integument, 
which later assumed a deeper hue, and, whether flattened or hemi¬ 
spherical, these papules were soon covered with a grayish or brownish 
crust, greasy to the touch and apparently prolonged into depressions 
beneath, much as the crust of seborrhea sicca of the face is sunk 
within the orifices of the sebaceous follicles. The papules, as they 
increased in size and age, became darker in hue until eventually they 
were a deep brown and red, or even purple. A few exhibited scratch- 
marks and were covered with hemorrhagic crusts. 

Over the scalp the symptoms are practically those of the crusting- 
forms of seborrhea, save that there is no tendency to loss of hairs. 
Over the face the parts chiefly involved are the temples, the inside of 
the concha of the ears, and the folds about the nares and lips. Here, 
as over the parts of the trunk named above, form dark, even blackish, 
strata of dirty oily crusts, spontaneously shed. Beneath each crust, 
as indicated above, there is usually a conical spur let into an infundi¬ 
bular depression, the latter representing the patulous orifice of a pilo- 
sebaceous gland. Over the backs of the hand and fingers the papules 
and crusts are less numerous, but the papules are closely set together 
and tend to coalesce. In the palms and soles are numerous almost 
imperceptible lesions of the same type. As the disease advauces to 
what has been described as a second stage, the papules coalesce, form¬ 
ing small tumors and papillomatous growths which involve not only 
the follicles, but also the interfollieular tissues. Many of the follicles 


1 Anual. de Derm, etde Syph., July, 1889. 

2 Contribution k l’Etude des Psorospermoses Cutanees, Paris, 1890. 

3 Journal Cutan. and Gen.-Urin. Dis., June, 1896. 


HYPER TR OPHIES. 


423 


become the sites of superficial ulcers, while the whole of the vegetating 
mass is bathed in a more or less abundant, fluid, muco-purulent secre¬ 
tion. The subjects of the malady often emit an offensive odor. 

The disease progresses gradually until large portions of the body are 
covered. Occasionally exacerbation with rapid spreading of the lesions 
occurs, but, as a rule, the course of the affection is slow and the general 
health of the patient does not seem to suffer except secondarily from 
the presence of ulcerating and suppurating lesions of the skin. 

Etiology . Little is known definitely regarding the etiology of kera¬ 
tosis follicularis. In the majority of cases recorded it began in child¬ 
hood, and in several instances in early infancy. In twenty cases 
collected thirteen were in males and seven in females 

The theory first advanced by Darier, and later elaborated by Wick¬ 
ham and others, that this variety of keratosis, and probably also Paget’s 
disease, some superficial forms of epithelioma, and molluscum u conta- 
giosum,” were due to the presence of psorosperms or coccidise, has 
practically been abandoned even by its propounders. As a result of 
further study by Bowen, Buzzi, Miethke, Boeck, Darier, and others, 
these bodies, which closely resemble certain psorosperms, have been 
demonstrated to be produced by cell-transformation. 

White’s two cases were in father and daughter, while Boeck had 
three cases in one family. It is possible that contagion or heredity 
may have an influence in the production of the malady. 

Pathology. The disease seems to be primarily a hyperkeratosis 
involving the sebaceous follicles and the hair-follicles. The process 
is confined for the most part to the neck of the follicle, but in the 
later stages it extends deeper and to the interfollicular tissues. The 
mouths of the pilo-sebaceous ducts are dilated into funnel-shaped open¬ 
ings and packed with masses of horny cells produced by the hyper¬ 
keratosis. Boeck and a few other observers believe, however, that the 
process is not essentially follicular, but that it may begin outside the 
ducts. 

The rete is usually thickened and in the later stages of the disease 
the interpapillary processes are prolonged. Mitoses are numerous, 
and in the lower layers of the rete are found fissures or lacunae, whose 
exact significance is not yet determined. In places the pressure of 
the horny masses may produce a thinning and atrophy of the rete. 
About the borders of the lesions there is an abundant pigment-deposit 
in both the epidermis and in the corium. The only other change noted 
in the corium is a very small amount of cellular infiltration. The 
glands of the skin are unaltered. 

The round bodies formerly supposed to be psorosperms are found 
in the deeper and middle layers of the rete, and at the base of the 
horny plug filling the follicle. According to Bowen, they are swollen 
cells containing a nucleus which stains deeply and which is sur¬ 
rounded by a clear or hyaline ring of protoplasm, outside of which 
is a zone containing granules of keratohyalin, the whole being sur¬ 
rounded by a homogeneous, glistening membrane, which may possess 
a double contour. Various modifications of this type are found as a 
result of irregular keratinization of the cells. In the upper layers, 


424 


DISEASES OF THE SKIN. 


in which the process of cornification is advancing, the keratohyalin 
gradually disappears; but it may do so irregularly, and, losing its gran¬ 
ular appearance, may give rise to appearances closely simulating nuclei 
and nucleoli. In the upper layers also the outer membrane may con¬ 
tract or disappear, leaving instead an empty space. At the bottom 
of the horny mass in the follicle the stratum granulosum is frequently 
absent, and there are seen irregular, shrunken, homogeneous cells with 
nuclei which stain but feebly. These cells are the “grains” of 
Darier, and Bowen thinks they are cells which have become cornified 
without passing through the keratohyalin stage. 

The subject of protozoan (coccidioidal) infection of the skin and 
other organs has been the subject of recent careful investigation with 
experiments by Messrs. Rixford and Gilchrist. 1 

Diagnosis. The disease is to be clearly differentiated from mollus- 
cum epitheliale, which is never so generalized, and which always 
exhibits an enucleable mass containing the so-called “ molluscous 
bodies.” The corneous forms of acne are eruptive elements which 
contain centrally a true corneous mass; in keratosis follicularis there 
is a softish comedo-like central mass. The acne-forms, further, are 
not generalized. In typical pityriasis rubra pilaris there can always 
be recognized over the dorsum of one or more phalanges, minute, iso¬ 
lated and scale-capped papules, which are manifestly pierced each by a 
hairy filament, the best single diagnostic feature of the malady. 

Treatment. So few cases of the disease have yet been observed that 
the treatment is still undetermined. While marked improvement may 
be obtained, no complete recovery has been reported, and with a lapse 
in treatment the unfavorable condition of the patient quickly returns. 
The parts are to be well cleansed by shampooings, and then dusted 
with borated, salicylated, and absorbent powders. The French, acting 
upon the parasitic theory of the nature of the affection, vigorously 
employ parasiticides, salves containing pyrogallol or iodoform, and 
even resort to cauterizations with the chlorid of zinc. 


[D] Keratodermia Palmaris et Plantaris. 

(Symmetrical Keratodermia of the Extremities, Congenital 
Keratoma of the Palms and Soles [Unna], Ichthyosis 
Palmaris et Plantaris.) 

A symmetrical and well-marked thickening of the palmar and plantar 
epidermis occurs as a result of several effective causes to which special 
attention has been directed, in France by Besnier and Doyon; in 
Germany by Unna; and in the United States by the author, 2 in a 
communication, in 1887, to the American Dermatological Association. 

Symptoms. Four varieties, the distinction between which is toler¬ 
ably clear, have been identified. 


1 The Johns Hopkins Hospital Reports, vol. i., Baltimore, 1896. 

2 Observations on Three Cases of Symmetrical Hand and Foot Disease. Med. News, Oct. 8,1887. 


HYPER TR OPHIES. 


425 


In the first variety there is symmetrical thickening of the palms 
and soles, strictly congenital and accompanied or not by nsevi situated 
upon other regions of the body. The epidermis of the involved areas 
is greatly thickened and a delicate erythematous halo extends beyond 
the border of the keratosis. The latter condition occasionally sweeps 
beyond the palmar and plantar regions to the dorsum of the affected 
fingers, toes, hands, or feet. The nails, the teeth, and the hair are not 
involved. 

The second group includes the more common variety of symmetrical 
keratodermia of the extremities developed during the second infancy, 
erythematous in type and possibly associated with a central neurosis. 
Here the epidermal thickening is exaggerated over the points of 
special pressure, though occurring independently of such agency, a 
fact well illustrated in a case where the thickening at times de¬ 
veloped while the patient was for months reclining in a hospital-bed. 
The disorder is worse in winter. There is the usual hyperemic zone 
at the border-line of the keratosis, and a great distinctness of definition 
of the latter with perfectly sound skin between the islets of epidermis 
sclerosed at the points of pressure. There is usually a coincident 
hyperidrosis, and a dislocation aod structural change of the nails them¬ 
selves. The keratinized sole or palm sheds its horny envelope either 
as a result of treatment or spontaneously; and even in the most pro¬ 
nounced cases the disorder may yield completely. 

In a third form there are foci where the keratosis is declared in 
multiple isolated points over the palmar and plantar regions, always 
independently of pressure and contact—due to a central tropho¬ 
neurosis. In a subvariety the orifices of the sweat-pores are distended 
by corneous plugs, resembling comedones, with concentric lamellations. 

A fourth variety is a partial, entirely curable, and accidental kerato¬ 
dermia of the extremities that is not to be confounded with the 
callosities described in another chapter. This form occurs at any age 
under the influence of pressure to which the limbs are unaccustomed. 

The diagnosis of all forms is to be made from eczema, chiefly by 
reason of the absence of well-marked inflammatory symptoms, of vesi¬ 
cles, and of eczematous patches in other regions of the body. Palmar 
and plantar syphilides are to be distinguished with great caution. 
These last may be asymmetrical, especially if of “late” type; may 
exist where there is often a history of infection or signs of lues; aud 
may often ulcerate. They have also well-defined circinate borders; 
and the lesions are more often multiple and isolated. 

Treatment. Internal treatment is by the methods employed in 
psoriasiform affections. Brocq advises the internal administration of 
arseniate of sodium in large doses ; but in this connection it should be 
remembered that cases are reported in which keratosis of the palms 
and soles has apparently been produced by a long course of arsenic. 
The local treatment is by prolonged maceration of the parts, followed 
by shampooings with green soap in substance or tincture, followed by 
salicylated pastes, plasters, or solutions of salicylic acid in collodion. 
Mercurial plasters and mercuric oleates may also be used with advan- 


426 


DISEASES OF THE SKIN. 


tage. Hydrate of potash in 10 to 20 per cent, strength has been applied 
as a lotion to stimulate the surface. Other formulae recommended 
are salicylic acid and calomel, one part of each to twenty parts of the 
glycerole of starch; and one part each of resorcin, tartaric acid, and 
salicylic acid, to twenty or thirty parts of the salve-basis. 


[E] Angiokeratoma. 

(Keratoangioma.) 

Angiokeratoma is an affection of the skin, chiefly of the hands, the feet, the face, 
and the scrotum, characterized by the development of commingled macular and 
translucent wart-like, larger and smaller, nodular lesions, associated with vascular 
changes in the parts affected. 

This disorder was first described in 1889 by Mibelli; 1 later, cases of 
a similar character though differing in many details have been reported 
by Thibierge, Crocker, Zeisler, Pringle, Joseph, Fordyce, Cottle, and 
others. The cases are rare and they apparently occur with wide di¬ 
vergence of type. 

Symptoms. The lesions may be first recognized upon the hands, where 
they resemble ordinary perniones, and are seated on the dorsal aspect 
of the fingers, especially of individuals who are much exposed to low 
temperatures or who handle cold materials in the trades, as, for example, 
in those who dress cold beef in winter. Both the palms and the soles 
may be invaded. Here, as over other regions of the body involved, the 
symptoms are displayed iu commingled pin-head-sized and larger, trans¬ 
lucent, horny-capped, roundish warts, tumors, or nodules, dull purplish 
in color, leaden-hued, or even chocolate-tinted, interspersed with flat 
macules (split-pea-sized for the most part, having a dark central punc¬ 
tual), which are at first removable by pressure and which eventually 
persist. These lesions are often plainly mere cutaneous varices. The 
globoid nodules may be smooth and horny at the surface or be rough¬ 
ened and prickly; they are never scaly. At times the varicosities of 
vessels are commingled with both spots and nodules, transitional forms 
between them occurring in some cases. The arrangement of the lesions 
is in general irregular and asymmetrical, though there may be some 
grouping. 

Etiology. The patients are commonly young, but a few cases have 
been reported in middle-aged subjects. There is usually a history of 
exposure of the affected parts to cold weather or to cold substances, 
as described above. Some of the sufferers from the disorder seem to 
have been subject to chilblains. 

Pathology. The first morbid change is a blood-stasis which results 
in punctiform capillary varices in the upper vascular web of the corium. 
Superimposed on these varicosities lie thickened areas of the epidermis, 
with acanthosis, constituting a keratomatous tumor. The epithelial 
ridges in the vicinity of these minute wart-like bodies are compressed 


1 Giorn. Ital. d. Malatt Vener, e delle Pelle, September, 1889. 


HYPER TR OP HIES. 


427 


and thinned by the ectasis of the vessels. The rete is commonly 
unchanged, though the granular layer is increased in thickness and the 
lower part of the stratum corneum shows increase in eleidin. At the 
moment of fullest evolution the affected papillae are transformed into 
small cavernous angiomata, sometimes reaching upward to the epidermis, 
while thinned processes of the latter stretch downward toward the 
cutis. The sweat-pores are at times narrowed; at others they seem 
to be normal. 

The prognosis is favorable, as the lesions may be made to disappear 
under proper treatment. 

Treatment is by stimulating lotions and liniments, as in pernio, and, 
when required, by electrolytic destruction of the vascular warts. 


[F] Keratosis Follicularis Contagiosa. 

H. G. Brooke 1 describes by this term a rare and apparently conta¬ 
gious disorder occurring in children. Blackish macules were symmetri¬ 
cally developed into deeply pigmented papules over the neck, the 
shoulders, and the arms. From these papules protruded blackish 
specks, which later resembled comedo-plugs and eventually developed 
as spine-like filaments. The skin, however, was dry, never greasy, 
and the thorny excrescences were quite firmly attached to the tissue 
beneath. The disease was found to be essentially a hyperplasia of the 
epithelial cells, the first evidence of the operation of the external cause 
being apparent in the stratum granulosum, the chief result being 
declared in the common excretory duct of the pilo-sebaceous conduit. 
The disease was readily relieved by applications of lard saponified with 
caustic potash. 


[G-] Hyperkeratosis Striata et Follicularis. 

H. v. Hebra 2 reports under this title the case of a young woman 
with isolated epidermic elevations, having a reddish margin, of both 
superciliary arches, over the bridge of the nose, the upper lip, the 
throat, shoulders, and arms. The lesions were flat or elevated, isolated 
or confluent nodules, constituted of heaped-up epidermis which could 
be removed without disturbing the papillary layer of the corium. 
Many were bean-sized, grayish-green elevations, conspicuous over the 
elbows, with underspreading epidermic cones buried in corresponding 
depressions beneath, which often bled freely when the cuticular mass 
was removed. Contrasting with these lesions were striated elevations 
of epidermis extending either at an angle or along the longitudinal 
axis of the limb. The disorder was relieved by warm-water and soap 
baths, followed by resorcin-vapor and salicylated plaster. 


1 International Atlas of Rare Skin Diseases, xxii. 1892. 

2 Ibid., v. 1891. 


428 


DISEASES OF THE SKIN. 


[H] Parakeratosis Scutularis. 

This name has been given by Unna 1 to a rare condition occurring in 
a vigorous man (first on the scalp) where thick, somewhat greasy crusts 
enveloped bundles of hairs, the separate filaments having yellowish 
and horny cuffs that were confused with the crust. Whitish scales 
and horny cylinders of perpendicular projection were visible over 
several portions of the face. Upon parts of the trunk were brownish 
spots, coin- to palm-sized, exhibiting horny cones which projected from 
the follicular orifices. The cones were covered with horizontally placed 
scales. Dark-reddish, moist, and shining surfaces were exposed on 
their removal. Closely examined, the horny cones after this removal 
displayed several hairs which projected, one above another, from each 
cone, having been extruded from their follicles at different times. The 
author believes the disease to be allied to Devergie’s pityriasis pilaris. 


MOLLUSCUM EPITHELIALE. 

(Lat. molluscus, soft.) 

(Molluscum Verrucosum, Molluscum Sebaceum, Epithelioma 
Contagiosum, Molluscum Contagiosum [Bazin], Acne vari- 

OLIFORME.) 

Statistical frequency in America, 0.139. 

Epithelial mollusca are smooth, globoid or acuminate bodies, situated either within 
or upon the skin, and in the latter case either sessile or pedunculated, varying in 
color from a yellowish-white to a dark-pink, and in size from that of a pin-head 
to that of a bean. 

Molluscum epitheliale, a disease first recognized in 1817 by Bateman, 
under the title Molluscum Contagiosum, is to be distinguished from 
another, known for a long time as molluscum fibrosum. The two dis¬ 
orders are quite distinct, and are no longer to be confounded by a sim¬ 
ilarity in their names. 

Symptoms. Typical epithelial mollusca are firm, roundish bodies, 
averaging in size the dimensions of a pea, and in color varying from 
a waxy whitish hue, nearly that of the integument, to the dark-red 
tint of all injected masses. They are either imbedded in the skin or 
project from it in semiglobular, sessile, or pedunculated tubercles. 
Usually a dark-colored aperture can be detected at the apex or side of 
the lesion from which, on pressure, milky and curd-like, semifluid 
contents can be made to exude. Occasionally inspissated or even horn¬ 
like masses project from these orifices, as though forced out by a vis- 
a-iergo. The disease is rare, and the lesions are usually single and iso¬ 
lated, though hundreds may appear upon the person of one individual. 
They consist of semifluid collections derived from that portion of the 
rete which either lines the sebaceous glands or penetrates between the 


1 International Atlas of Rare Skin Diseases, i. 1890. 


HYPER TR OPHIES. 


429 


papillae of the derma; or they are actual transformations of the glands 
into cornified amorphous deposits, surrounded by thickened parietes. 
They may artificially be removed; or be shed spontaneously ; or inflame, 
and result in circumscribed abscesses; or terminate by ulceration. 
More often they are insidious and slow of development, and may per¬ 
sist for years without producing annoyance or subjective sensation. 
They occur on the face, the side of the neck (Fig. 49), and the nucha; 
on the penis and scrotum of men, and the breasts and labia of women; 
on the trunk ; on the flexor surfaces of the extremities, and the dorsal 
surfaces of the hands and feet. They are most common in children. 


Fig. 49. 



Molluscum epitheliale. (After Allen.) 

In consequence of the depression of the centre of the little tumors 
(which Hutchinson has aptly likened to small pearl buttons) they may 
suggest the lesions of variola, hence they were described by Bazin 
under the term Varioliform acne. This title, however, is by most 
writers employed to designate a totally different affection, a variety of 
acne vulgaris, to which a chapter is devoted in this work. 

Hebra, Virchow, and Nicolaysen have reported colossal mollusca, 
as large as an orange or a small cocoanut. Microscopical examination 
of these gigantic lesions demonstrated their identity with the smaller 
tumors. Similar bodies of less, size have been found interspersed among 
epitheliomata. 

Etiology. In England, where the disease was first recognized and 
where, according to Hutchinson, it is far more frequent than on the 


430 


DISEASES OF THE SKIN. 


continent of Europe, the belief in its contagiousness is quite generally 
accepted. Excellent authorities, however, are divided upon this ques¬ 
tion. At present the contagiousness of molluscum is not yet estab¬ 
lished, though the belief in that doctrine is unquestionably increasing. 
If contagious, the lesions must possess this power of transmission in 
an imperfect degree, one certainly much inferior to others recognized 
as contagious, Retzius, Vidal, Peterson, and Wigglesworth succeeded 
in producing the disease by inoculation of the contents of molluscous 
tumors. Allen, in an interesting communication upon the subject , 1 
reports an abortive result from an inoculation practised in two places 
upon himself by Dr. Bulkley. He reports fifty cases of the disease 
observed among children in an infant-asylum of New York City, and 
expresses himself strongly in favor of the contagious character of the 
disease. Experiments with inoculation have, however, often been 
unsuccessful. The proofs of contagion rest chiefly upon the circum¬ 
stance of lesions being simultaneously or successively observed on the 
breast of a mother and the mouth of her nursling, as noted by both 
Bateman and Allen, or upon the successive development of mollusca 
in several members of one family. Fox, of New York, has called 
attention to an interesting relation which would seem to subsist between 
mollusca and verruca, or ordinary warts. If simple warts are ever 
shown to be in a feeble degree contagious, it can scarcely be doubted 
that a demonstration of the contagiousness of mollusca will soon follow. 

Stelwagon 2 has accumulated and classified reports of cases and of 
inoculations which seem to leave little doubt as to the parasitic nature 
of the disease. Eczema, sweating (Turkish baths), pruritus, and macer¬ 
ation of the skin predispose to the occurrence of mollusca; but there 
are insufficient grounds for assuming that, in adults, they are associated 
with venereal disease. They are not rarely seen in large numbers upon 
the scrotum of youths who have never exercised the sexual function. 

Pathology. Sections through the centre of a lesion of molluscum 
contagiosum (epitheliale) show that it is formed by a number of diverg¬ 
ing flask-shaped lobules, the small end of each opening into a common 
central cavity. The lobules are separated 
from each other by a thin fibrous partition, 
which may occasionally be demonstrated to 
be the remains of a papilla. The entire 
mass or group of lobules is surrounded, 
except at the surface-opening, by a fibrous 
capsule, thus giving the entire structure 
an appearance very similar to that of a 
sebaceous gland. The belief, formerly 
held by some observers, that the process 
originated in the sebaceous gland, is now 
known to be erroneous. Minute examina¬ 
tion fails to find any trace of a sebaceous 
gland in these formations. Their exact origin is still a disputed ques¬ 
tion. It is quite probable that they occasionally originate in the 


Fig. 50. 



Molluscous corpuscles. 
(After Kaposi.) 


* Journal of Cutaneous and Venereal Diseases. August, 1886. 

- Journal of Cutaneous and Genito-Urinary Diseases, February, 1895. 




HYPERTROPHIES. 


431 


epithelium lining the mouths of the follicles, but in the majority of 
cases it is now believed that the process begins as a proliferation of 
epithelial cells in the lower layers of the rete. The growth is confined 
to the rete, from which the flask-shaped processes are pushed out, 
causing a flattening and more or less complete disappearance of the 
underlying papillae. 

Each lobule is lined with a layer of palisade-cells continuous with 
the same layer in the healthy rete adjoining the growth, and is filled 
with round and cuboidal nucleated epithelium undergoing peculiar 
changes. The first two or three rows of cells are usually normal, but 
above them the changes become gradually more and more marked. 
The exact nature, sequence, and signification of these changes are in 
dispute, but it would seem to be fairly well established that the outer 
part of the cell shows early in the process abundant granules of kerato- 
hyalin, and soon undergoes a cornification forming a clear ring or 

capsule ” for the cell. Within, the changes are similar to those seen 
in amyloid or colloid degeneration. Authors describe a granular con¬ 
dition surrounding the nucleus which is usually at one end of the cell, 
while the remainder of the cell-protoplasm shows vacuoles or groups 
of small, irregularly shaped, hyalin bodies, uniting to form an oval 
mass which gradually encroaches upon and distends the cell. This 
oval homogeneous corpuscle surrounded by a horny capsule forms 
the so -called u molluscum body.” These bodies accumulate at the 
mouths of the lobules and in the small common cavity into which the 
lobules all open, and may be pressed out upon the surface of the skin 
in a yellowish, or whitish, semifluid or waxy mass. 

The more minute changes in the cells and the methods of recognizing 
them are given in detail by Unna 1 and others. The theory that the 
disease is caused by psorosperms is rapidly losing ground among recent 
observers, though it is not at all improbable that a parasitic origin of 
the disease will yet be determined. 

Diagnosis. Mollusca resemble the lesions of variola more than any 
other cutaneous phenomena. They are, however, readily distinguished 
from the latter by their chronicity, their semifluid contents, the absence 
of febrile symptoms, and the career of the variolous pustules. From 
warts they are also differentiated by their contents, hemispherical shape, 
and the dark punctum almost invariably present on one part or another 
of the lesion. 

Molluscum epitheliale in no way suggests molluscum fibrosum, with 
which it has only been confounded in consequence of the similarity in 
the two names. The tumors of molluscum fibrosum are solid new 
growths, usually occurring in great numbers upon the trunk of individ¬ 
uals in adult years. They may attain enormous dimensions, of several 
pounds’ weight, and though in cases they degenerate by ulceration, 
they never have the curdy contents of molluscum sebaceum. 

Papillary warts are to be distinguished from mollusca, though with¬ 
out question lesions are to be occasionally seen of a type intermediate 
between the two forms. Warts are to be recognized by their general 


1 Histopathology of the Diseases of the Skin, 1894. 


432 


DISEASES OF THE SKIN. 


papilliform character, and their evident relation to the papillary layer 
of the corium overlaid by a thickened stratum corneum. 

Physicians are occasionally consulted by patients who have discov¬ 
ered mollusca upon the genitals, and who suppose these legions to be 
of venereal origin. An error in this respect can scarcely be committed 
by the expert. Neither the solid papule of the initial lesion of syphilis 
when observed on the skin of the penis, nor the pustule and resulting 
ulcer of the chancroid, ever exhibit the particularly waxy look of 
genital mollusca with their depressed puncta. In such cases the 
inguinal glands should always be carefully examined, remembering, 
however, that a forcibly squeezed and cauterized molluscum may be 
accompanied by a sympathetic adenopathy. 

Treatment . Molluscous tumors may be removed by ligature, scissors, 
knife, curette, or the needle in contact with the negative pole of a 
galvanic battery, their contents having previously been expressed. 
When desired the affected surface may first be chilled or frozen with 
the ether-spray, to diminish the pain of the trifling operation. Bleed¬ 
ing is easily arrested by a pledget of lint. Occasionally the point of 
a crayon of nitrate of silver may be introduced, after their removal, 
either to check hemorrhage or to insure destruction of the cyst. Accord¬ 
ing to Hebra, the return of the complaint, when it occurs at all, may 
be expected at points where no tumors have been removed. 

When the lesions are small and numerous they may be made to 
exfoliate by the local application of green soap. Removal of the 
larger lesions may be followed by minute cicatrices. 

Prognosis . The disease can always be terminated by removal of 
the tumors, the process to be repeated in case of recurrence. Cica¬ 
trices, when these result, are of trifling moment. 


Callositas. 

(Lat. callus , hard flesh.) 

(This condition is also termed Tylosis, and the callosity itself Tyloma 
or Keratoma.) 

A callosity is a whitish-gray, yellowish-gray, or brownish, semi-transparent, local¬ 
ized and circumscribed horny thickening of the epidermis of the skin, due to 
hypertrophy of the stratum corneum, most commonly occurring upon the hands 
and feet. Callositas is here employed to designate strictly acquired horny thick¬ 
ening of the epidermis. Under the title Keratosis are described a series of con¬ 
genital and other symmetrical thickenings of both palms and soles, tylotic and 
ichthyotic in type, often the result of morbid conditions in the nervous centres 
and entirely unconnected originally with pressure- and contact-effects. 

Callosities are superficial, circumscribed, dirty-white, yellowish-white 
or darker, flattened, thickened, and horny patches of epidermis, dense 
in structure and usually insensitive. Section of a single plaque shows 
it to be largest at the centre and least at the periphery. Callosities vary 
in size from that of a finger-nail to that of a section of a hen’s egg, being 
















































































> 




















































































































PLATE III. 




Malum Perforans Pedis, with Symmetrical Keratoma of the Palms and Soles. 


[From a water-color sketch of one 01 the author’s patients.] 



IIYPER TR OPHIES. 


433 


at times larger; they occur chiefly upon parts of the integument sub¬ 
jected to long-continued intermittent pressure, as the hands and feet; 
also upon parts stretched over osseous prominences, as those over the 
ischia. They may be complicated by hyperemia, fissure, acute inflam¬ 
mation, or erysipelas; and readily serve as foci of cutaneous disease 
(eczema, psoriasis, etc.). They are commonly encountered among 
mechanics, carpenters, shoemakers, etc.; among persons wearing ill- 
fitting shoes (heel, ball, or big toes), stockings, or surgical apparatus; 
among workers in metals, acids, or heated substances; and among 
musicians (harpers, banjo-players, etc.). They are produced by such 
external causes as pressure, friction, chemical agents, and heat. By 
careful consideration they can readily be distinguished from eczema¬ 
tous, psoriasic, and ichthyotic patches, being always limited to the 
sites of external contact. 

Callosities are so characteristic of the several professions and trades, 
that by their locality alone they point in many oases to the occupation 
of the individual who exhibits them. Often they are, in these cases, 
esseutial to the prosecution of such work; and their removal would only 
expose a tender epidermis to the operation of an injurious pressure or 
friction. 

They are, pathologically, pure hypertrophies of the stratum corneum 
of the epidermis, the deeper layers of the latter as also the corium and 
subcutaneous tissue being quite unaffected. 

Callosities require treatment only when they are sources of pain or of 
discomfort. They may be removed—surgically, by the knife; chem¬ 
ically, by the destructive action of acids or alkalies; rationally, by 
disuse of the part to an extent sufficient to interfere with the operation 
of the cause. When painful they may be poulticed. A nightly soak¬ 
ing of the callus with warm oil, kept in contact with the thickened 
epidermis during the hours of sleep by a compress of flannel saturated 
with the same substance, will in the end always soften the induration. 

Callositas of the Hands, with Unusual Complications (re¬ 
ported by Morison , 1 of Baltimore), is illustrated by the case of a 
negro who was engaged in stoking the fires of a steamer. In this 
instance the combined effects of heat and friction resulted in ulcera¬ 
tions beneath the callosities that eventually produced necrosis and fall 
of some of the phalanges. This patient recovered as soon as the hands 
were properly protected, a fact which seems to justify the assignment 
of this and similar cases to a class apart from those which follow. 

Perforating Ulcer of the Foot (Malum Perforans Pedis; 
Mai Perforant du Pied). This disorder, first named by VesignS, has 
been studied by Savory and Butlin , 2 Treves , 3 Duplay , 4 Michaud , 5 and 
others. The name is an unfortunate one, since many cases to be classed 
only in this category have neither ulcerative nor perforating symptoms. 

Symptoms. Tim first symptom is a proliferating thickening of the 
epidermis like a corn, usually single, occasionally multiple, appearing 

1 Journ. of Cutan. and Vener. Dis., Jan. 1886. 2 Med.-Chir. Trans., vol. lx., 1879. 

3 Lancet, Nov. 29,1884. 4 Arch. g6n. de M6d., 1876. 

5 Lvon Med., 1876. 


28 


434 


DISEASES OF THE SKIN. 


over a point of pressure (first or fifth metatarso-phalangeal joint, etc.). 
Inflammation and suppuration proceed beneath this thickening, spread¬ 
ing first to the soft parts of the sole and then to the bone itself. Grad¬ 
ually a sinus forms, reaching from the side of the corn to the deeper 
parts involved. Meantime the skin in the neighborhood becomes 
greatly thickened, heaping itself especially about the sinus. The ulcer 
which eventually forms is roundish, deep, and at times very destructive 
in its effects. 

Thus far the lesion might be supposed to be the result merely of a 
greatly irritated corn, but other phenomena exhibited in these cases are 
quite inexplicable in this way. The nails are altered; superfluous hair 
grows on the dorsal surface of the foot and the skin of the involved 
extremity; pigmentation, erythema, or eczema may occur; and the 
parts may become affected with either anidrosis or hyperidrosis. These 
disorders have, again, been noted as the result of spinal injury, con¬ 
gelation, posterior spinal sclerosis, anesthetic leprosy, and, in animals, 
after section of the sciatic nerve. Among the commonest symptoms 
in typical cases are anesthesia, neuralgic and rheumatic pains, hyper¬ 
idrosis, and coldness of the feet. 

Perforating ulcer is illustrated in the following case: 

In the centre of a dense callosity which had formed over the right 
first metatarso-phalangeal articulation of a young man, there was 
exposed the orifice of a sinus which could not be made to close. The 
course of the disease was exceedingly indolent, the parts being the seat 
of little pain. The weeping from the sinus was scanty, and it was 
not surrounded by granulations. It was more of an annoyance at first, 
than a serious disease. Finally, by the aid of a fine probe, it was dis¬ 
covered that the sinus beneath led to exposed bone. A deep incision 
was made at this point, and the osseous surface thoroughly scraped, 
after which antiseptic dressings were applied. The sinus, however, 
re-formed in time; and it finally became necessary to amputate the toe 
and remove by the gouge a large portion of the head of the correspond¬ 
ing metatarsal bone. This operation proved successful in relieving 
the patient. 

In a group of cases of perforating ulcer of the foot there is gene¬ 
rally a symmetrical involvement of the entire sole or palm, either of 
both feet, or of both hands and feet. The patients are often young 
adults. The palms when involved never exhibit the translucent, yel¬ 
lowish, wash-leather-like appearance of the same condition of the 
soles, but rather suggest the dry, scaly features of the palms in certain 
forms of erythematous eczema of these parts, but always without 
itching, and always with coincident plantar tylosis. The soles, how¬ 
ever, present the typical appearance of callositas throughout the entire 
region, the callosity reaching somewhat upward over the heel, and in 
certain patients relatively sparing the instep. In some cases the nails 
are not involved. The feet are always as cold to the touch as in 
pernio. 

Pathology. The disease is, without question, a trophoneurosis, and 
may be due to injury to a nerve-centre, as in tabes dorsalis; to a nerve- 
trunk, as in syphilis or leprosy; or to the terminal nerves. Histological 


H YPER TR 0 PHIES. 


435 


examination has shown destruction of the myelin and axis-cylinder of 
twigs of nerves supplying the affected parts. According to Savory 
and Butlin, the sensory and nutrient fibrils of the involved nerves 
degenerate in consequence of pressure exercised upon them, by increase 
of the endoneurium, the motor fibrils escaping, owing to their large 
size and thicker medullary sheath, a view plainly untenable for all 
cases. 

Diagnosis. The diagnosis is between tuberculosis and simple callos- 
itas, a distinction readily established by the evident neurotic phenom¬ 
ena seen in the perforating disease of the foot. 

Treatment. Apart from surgical interference called for by one class 
of cases, a roborant treatment, including the internal administration 
of iron and arsenic, has been followed by most favorable results. 

The prognosis is doubtful. 


CLAVUS. 

(Lat. clams, a nail.) 

(Corn. Fr ., Cor, CEil de Perdrix ; Ger. y Huhnerauge.) 

Clavus, or corn, is a circumscribed callosity usually found upon the toes, due to 
epidermal hypertrophy, and provided beneath with a conical spur of horny tissue 
which is projected into a corresponding depression in the corium. 

Corns are hypertrophies of the horny layer of the epidermis, with 
the peculiarity of presenting interiorly a coniform prolongation, which, 
being pressed from without inward upon the sensitive papillae of the 
corium, excites pain in various degrees. Corns vary in size from that 
of a pea to that of a large chestnut, and are dense and callous when 
occurring upon those prominent parts of the foot where the boot, shoe, 
or gaiter exercises its greatest pressure. When occurring upon the 
lateral face of a toe in apposition with another the corn originates 
usually from pressure through the medium of the neighboring digits. 
It is then softer, from exposure to greater heat and moisture. Corns 
are often weather-sensitive, being unusually painful before, during, or 
after the occurrence of storms, and should, therefore, not be confounded 
with gouty or rheumatic -deposits below the skin. They are composed 
of superimposed, and often concentrically arranged, layers of epithe¬ 
lium, between which are occasionally found minute hemorrhagic extrav¬ 
asations. They are occasionally seen upon the palms of the hands. 

At the periphery of the corn the corium is unchanged, but at the point 
where its central cone is pressed into the deeper structures the papillae 
are either atrophied or quite absent. 

Treatment. Corns are rationally treated by disuse of the feet, or by 
the adjustment of properly fitted coverings for the same. They usually 
fall spontaneously after an attack of paraplegia and in the cases where 
the lower extremities are confined for a few weeks in surgical apparatus 
for relief of a fracture. They may be softened by prolonged macer¬ 
ation in water, by poultices, or, best of all, by oil, as in the treatment 


436 


DISEASES OF THE SKIN. 


of callosities. Erasion and excision may be practised, if demanded 
by an exigency. Where the sufferer must necessarily continue the use 
of the foot the simplest and best treatment is as follows: The part is 
thoroughly macerated for half an hour with water as hot as can be 
tolerated. Then the projecting callous portion of the corn is gently 
removed by cutting or scraping until, as nearly as may be, the surface 
is level with the plane of the adjacent skin. The part is then dried, 
and the entire surface, both of the seat of the corn and the adjacent 
integument, is completely covered with many narrow, short, and nicely 
adjusted strips of rubber plaster. When the trifling operation and 
dressing are complete, the patient should bear firm pressure over the 
corn without flinching, and walk with perfect comfort. The plaster 
remains until it separates spontaneously, which is usually in the course 
of a few days. The corn is then macerated at night with an oil-poul¬ 
tice, as described above, and the dressing afterward reapplied, usually 
the second time by the patient. Persistence in this course is followed 
by complete relief if the coverings of the feet be properly fitted. 
Caustics, employed by many, are usually unnecessary when there is no 
ulceration of the hard corn, and are in this situation frequent sources 
of great distress. They are chiefly valuable in the treatment of the 
soft variety, but they should always be applied with a skilled hand. 

For this purpose the crayon of nitrate of silver or acetic acid may 
be employed. The proprietary “ corn-salves” sold in the shops com¬ 
monly contain the ointment of the nitrate of mercury, which also is 
a useful application to the soft variety of corn. The latter should be 
protected by the interposition of absorbent cotton or wool from contact 
with adjacent digits. 

As a rule, the ringed corn-plasters sold in the shops are inferior to 
the dressing with the rubber or salicylated plaster, made to cover the 
entire corn. 


CORNU CUTANEUM. 

(Lat. cornu, a horn.) 

(Horn. Fr ., Corne de la Peau ; Ger., Hauthorn. ) 

Statistical frequency in America, 0.034. 

Cornua, or cutaneous horns, are circumscribed hypertrophies of the epidermis, 
forming irregularly shaped, spur-like excrescences of different sizes. 

Cylindrical, conical, straight or twisted, angular and otherwise 
irregularly shaped and sized corneous eminences, single or multiple, 
occasionally project from the scalp, forehead, nose, lips, ears, penis, 
or extremities. The sites of preference are in the following order, 
the scalp, forehead, temples, nose, lower extremities, male genitals, 
and trunk. Horns are named from their resemblance to the similar 
appendages in horned cattle, but they widely differ from cattle-horns, 
which are always implanted upon osseous tissue. They are formed 
of dense and massed columns of epithelia, often resting upon some¬ 
what prolonged papillae. Occasionally, on section, they exhibit the 


H YPER TB 0 PHIES. 


437 


concentric arrangement of the epithelia seen in corns, but, unlike 
the latter, have reentrant basal depressions into which the papillse 
below penetrate. At times they are implanted in a dilated follicle, in 
which case the glandular elements participate in their formation. At 
times, also, they represent a corneous transformation of the epithelia 
which constitute warts. They are seen in all colors, but are often 
between a yellowish-brown and a brownish-black, with a fissured or a 
wrinkled or longitudinally grooved exterior, like rough bark (Fig. 51). 

Fig. 52. 



Varieties of cutaneous horns. 


They may be painless, or, like other keratoses, become the seat of in¬ 
flammation in various grades. They may be short or several inches 
in length (Fig. 52). The largest specimen ever under the author’s 
observation was seen by him in France, on the forehead of a man, 
where it had existed for fifteen years. It measured three inches in 
length. They may be shed spontaneously, never to return, or may 
shortly reappear. They occasionally develop into epitheliomata, as has 
occurred once under the author’s observation, in a gentleman over 




438 


DISEASES OF THE SKIN. 


sixty years of age, whose epithelioma developed from a horn on the 
dorsum of the right hand, projecting about three-fourths of an inch. 

At the meeting, in 1887, of the American Association of Genito¬ 
urinary Surgeons, Brinton, 1 of Philadelphia, exhibited an anteriorly 
curved horn one and seven-eighths inches long and three-eighths of an 
inch in circumference, removed by him from the glans penis of an 
elderly patient, no member present having then seen a similar growth 
in that locality. Only fourteen cases were on record of a similar 
growth in this situation. 

In the horn growing from the lower lip of an elderly man exhibited 
in 1886, at the author’s clinic, the growth was longitudinally furrowed, 
aud also at somewhat regular intervals transversely seamed, presenting 
thus the appearance of the joints of the sugar-cane. 

The etiology is without question that of the senile wart for most 
cases; though, as with epithelioma, horns occur in infancy. They 
have been recognized as starting from a sebaceous cyst. 

Pathology. Pathologically these hypertrophies are first developed 
either within a closed atheromatous cyst, or from remarkably elongated 
papillae of the corium. They are made up of cornified and hyper¬ 
trophied epidermal cells. 

Lebert shows that horns develop into epitheliomata in about 12 per 
cent, of cases. As horns are really metamorphoses of epidermal cells 
similar in many points to warts, it is not surprising that the two often 
undergo the change from benign to malignant epithelial growths. In 
a few cases horns have developed to an appreciable degree on epithe¬ 
liomata; but under the microscope this horny metamorphosis on a 
smaller scale may be recognized in a large number of epitheliomata 
situated on the back of the hands of elderly men who have been farm- 
laborers, sewer-builders, or workers in contact with the earth. 

Treatment. Horns may be removed by extirpation, after which the 
surface upon which they were implanted should carefully and com¬ 
pletely be cauterized. 

Prognosis. In formulating a prognosis the possibility of an epithe- 
liomatous result should not be forgotten. 


VERRUCA. 

(Lat. verruca, an excrescence.) 

(Wakts. Fr.,v errue; Ger.,W arze.) 

Warts are pin-head-to bean-sized and larger, soft or hard, circumscribed elevations 
due to hypertrophy of both the epidermis and the papillae of the shin. 

Warts are cutaneous excrescences; sessile or pedunculated; pointed 
or flat; smooth, rugous, or having a cauliflower appearance; pigmented 
in various shades, or of the natural color of the skin; congenital or 
developing after birth. They may be single or multiple, and they 
occur upon the hands, feet, face, scalp, neck, genitals, and other parts 

1 Journal of Cutaneous and Genito-Urinary Diseases, 1887, p. 272. 





PLATE IV. 


Congenital Warts. 



[From a photograph ot one of the author’s patients.] 



HYPER TR OP HIES. 


439 


of the body. They may develop slowly or rapidly, and may persist 
for years, or disappear without apparent cause. They may be soft, 
dense, or even be corneous to the touch. 

The several names given to the various forms of warts have chiefly 
a descriptive value. 

Verruca Acuminata (Condyloma; Moist, Venereal Wart. Ger., 
Spizen Warzen ) is a filiform, papilliform, or cock’ s-comb-like vegeta¬ 
tion. They are single or multiple; at times hundreds coexist upon the 
genitalia and neighboring regions. In size they vary from that of a 
pin’s point to that of a hen’s egg, and may be larger. They are apt 
to be moist and secreting, being frequently covered with a puriform 
mucus of exceedingly nauseating odor. Upon the genitals they are 
encountered upon the glans, around the frenum, and over the prepuce 
of men; and in women, about the clitoris, labia, vagina, and anus. They 
are usually of a bright-red color in these situations. When occurring 
upon the integument they are firmer, drier, and exhibit a tendency to 
luxuriant growth. In this form they may be recognized about the 
axillary regions, the umbilicus, the interdigital spaces of the feet, and 
even the face. They may cover the side of the chin. 

The summit of these warts may be tufted, acuminate, or flattish; 
on the surface of the skin, unconnected with mucous membrane, they 
may have the color of the unaltered integument. They are often 
minute and numerous as well as multiple and large; or they may be 
single throughout, though, as a rule, they multiply when untreated. 
Their largest maximum development is olten observed in negroes, in 
whose persons they may attain unusual proportions. There was lately 
exhibited at the author’s clinic a male negro with a compound venereal 
wart of the penis that was of the size of that of the largest orange. 

These warts are almost always the result of exposure of the sexual 
parts to venereal secretions (blennorrhagic, syphilitic, leucorrheal, etc.), 
and, though observed in virgins, are decidedly rare in individuals of 
both sexes of that class. In pregnancy they often attain a large size 
and rapid development, but then, as a rule, disappear when parturition 
is completed. 

There is no doubt as to their contagiousness and of their furnishing 
an auto-inoculable secretion. Cocci and bacilli have been recognized 
in several varieties, thus explaining many otherwise obscure histories. 

Verruca Acquisita is a term used to designate lesions developed 
after birth. 

Verruca Congenita. Congenital warts are usually first noticed 
in the course of several months after birth. They may be single or 
be multiple, usually the latter, in which case they are arranged along 
the lines of distribution of the nervous trunks, the disposition of the 
lesions often suggesting the arrangement displayed in zoster of the 
trunk or other region. They are, as a rule, roundish, slightly pig¬ 
mented, scarcely larger than split peas. At times they acquire unusual 
dimensions. The neck and shoulders may be well covered with lesions 


440 


DISEASES OF THE SKIN. 


of this class in asymmetrical groups, the largest wart having the size 
of the section of an egg. 

Verruca Filiformis. This variety of wart differs somewhat from 
the others, not only pathologically, as is noted below, but also in its 
clinical features. These warts are pointed growths, slender, thread¬ 
like, often pedunculated, usually covered with a smooth and apparently 
unaltered epidermis; they occur upon the face, neck, eyelids, chest, 
and ears. Kaposi concludes that they represent minute fibromata. 1 

Verruca Glabra is distinguished by its smooth surface. 

Verruca Plana describes a not uncommon variety of wart which 
is flat, smooth, and but slightly elevated. The plane warts may be 
single, but are commonly multiple, and they usually vary in size from 
that of a pin-head to that of a small split-pea, but may be much larger. 
They are often grouped, and may have a polygonal outline, closely sim¬ 
ulating the papules of lichen planus. In young people these plane 
warts are usually small, multiple, often grouped; have the color of 
the normal skin or are slightly yellowish or whitish; and are seen most 
frequently on the forehead, other parts of the face, and on the backs 
of the hands. In older people this form of wart shows less tendency 
to grouping than in the young, is often pigmented, and may be associ¬ 
ated with or form the beginning of superficial epithelial changes. 

Verruca Senilis vel Plana (Keratosis Pigmentosa). These 
warts are bean- to coin-sized, smooth, and softish growths developed 
upon the face, trunk, and extremities of persons of advanced years. 
They are flat, usually pigmented, and have a granular aspect. They 
are readily separable by the finger-nail, and are then found to rest upon 
a reddish granular base. As the result of external injury (caustics, 
traumatism) they may become the starting-point of an epithelioma. 

Verruca Vulgaris is the form most frequently seen upon the 
fingers and hands, as pin-head- to pea-sized, usually discolored, papil¬ 
liform excrescences. 

Of the several varieties of warts it may be said, in general, that they 
are most frequently observed either on the hands or over the genital 
region; that they are usually discrete, but may be confluent and form 
palm-sized and larger elevated plaques; that they may be soft, hard, 
smooth, rough, pointed, flat, brush-like, or like the comb of a cock; 
that they may vary from a pinkish to a blackish hue; that they may 
persist, occur in crops, or spontaneously disappear; and that they may 
grow with great rapidity (Verruca acuminata) to a large size and 
involve any portion of the body. 

Fox, of New York, figured an interesting case in which warts 
occurred in the lines tattooed on the skin of a young man. 


1 See Dr. Taylor’s observations as epitomized in the chapter on Fibroma. 


HYPER TR OPHIES. 


441 


Etiology. Most warts are nests of micro-organisms of different varie¬ 
ties. The precise cause, however is, unknown; but in early child¬ 
hood, a period in which they are most frequently encountered, it is 
reasonable to conclude that they result from external contacts. It is 
when the child begins to handle everything within reach that they 
usually first appear, and then about the hands. Acuminate or condy- 
lomatous warts chiefly occur in parts moistened with a blennorrhagic 
secretion, but unquestionably they may originate from contact with 
leucorrheal or pathological, non-venereal discharges from the female 
genitals. Senile warts are more probably due to obscure changes in 
the nutrition of the integument. The etiological importance of the 
cocci and bacilli which many of them furnish cannot exactly be de¬ 
termined at this time. 

Pathology . The process probably begins with downward and upward 
growth of the rete cells, resembling in this respect benign epithelioma. 
The granular layer is remarkably thickened, while the greatly hyper¬ 
trophied horny layer is less compact than normal owing to imperfect 
keratinization of the cells, in many of which the nucleus is still appar¬ 
ent. The papillary layer of the corium is hypertrophied and the centre 
of each wart is made up of a connective-tissue papillary growth, in 
the centre of which is a vascular loop. In the pointed forms the 
connective-tissue and vascular elements are marked, while the horny 
layer is but slightly hypertrophied. In verruca plana the chief 
change is in the rete, the horny layer being but little thicker than 
normal. 

Diagnosis. It is a matter of importance to recognize the fact that 
many epitheliomas begin as warts; therefore the verruca of those 
advanced in years should always be examined and treated with a view 
to this fact. In any suspicious case the existence of one or more 
u perles” in the viciuity of a supposed wart should arouse suspicion; 
as also a tendency, especially in the aged, for the lesion to break down 
into an ulcer. Warts on the face and the backs of the hands of the 
aged are often of this class. 

Another class of warts are tuberculous in character, and, whether 
occurring in the young or the aged, are the result of infection with 
tubercle-bacilli, a generalized tuberculosis often originating in these 
lesions (vide Tuberculosis Verrucosa). 

Great care must be had to distinguish the moist variety from syph¬ 
ilitic condylomata. In the latter there is usually a history of con¬ 
tagion with other syphilodermata upon the surface, such as mucous 
patches, palmar lesions, or papules of the face. Fibroma, or molluscum 
fibrosum, generally occurs in tumors of greater number, firmer con¬ 
sistence, and larger size. The tumor of molluscum epitheliale greatly 
resembles a wart, but the waxy-whitish appearance of the lesion and 
its dark punctum at one point or another sufficiently distinguish it. 
In exceptional cases verruca plana may in shape and grouping closely 
simulate lichen planus, but the location and history, together with 
the absence of the typical color, the varnished appearance of the sur¬ 
face, and the itching, characteristic of lichen planus, will make the 
diagnosis clear. 


442 


DISEASES OF THE SKIN. 


Treatment. Warts may be removed by excision, erasion, or caustics 
(nitrate of silver, alkalies, acids, perchloride of iron, corrosive subli¬ 
mate, etc.). The larger growths upon the genitalia, that are often 
highly vascular, may demand the prior application of a ligature when 


Fig. 53. 



Vertical section of the summit of a pointed wart: a, papilla containing vascular loop; 
c, stratum corneum; d, hypertrophied rete. (After Kaposi.) 

they are pedunculated. Even the slender filiform warts will be found 
to contain a small vessel in each pedicle that requires cauterization after 
excision. When the warts cannot more readily be removed by the 
knife or by curved scissors the Paquelin cautery may be used. The 
blackened eschar which is left prevents hemorrhage, serves as the best 




HYPER TR OPHIES. 


443 


subsequent dressing, and is less apt to be followed by a return of the 
growth. In some cases it is a useful expedient to transfix the lesion 
in several directions with the long needles used in gynecological prac¬ 
tice, previously dipped in a 50 per cent, solution of chromic acid. 

One may also transfix the base of the wart a sufficient number of 
times with a needle connected with the negative pole of a galvanic 
battery, the positive pole being connected with the body of the patient 
by the aid of a moist sponge. 

The formula according to which are made several of the proprietary 
“ wart-cures ” sold in the shops, is as follows: 


R.—Acid, salicylic., ^ss; 2! 

Cannabis Indie, extr., gr. v; j33 

Collodion, -|ss; 16] M. 

Sig.—To be painted over the wart with a camel’s-hair brush. 


For small multiple warts Morris recommends the following: 


R •—Glycerin., 3 jss ; 

Acid acetic, dil., ^ijss; 

Sulphur, precipit., 3j ; 


6 

10 

4 


M. 


For patches of warts Van Harlingen recommends cautiously attack¬ 
ing one part at a time with the following paste: 


R •—Pulv. acid, arseniosi, gr. vj ; 


40 


8 


M. 


For warts not requiring operative removal local treatment often 
answers well. Those about the genital region often disappear if per¬ 
sistently washed with a solution of tannin in alcohol, 1 drachm (4.) 
to 3 ounces (96.), after which they are dried and thoroughly dusted 
with boric acid, or salicylic acid with lycopodium, or burnt alum and 
rosin, or, what is most popular, dry calomel. Alum and lead lotions 
may also be substituted for the tannin and alcohol, and for a time be 
kept over the parts on a compress. 

Prognosis. Warts are benignant growths; in childhood and in early 
adult life they need not suggest grave sequels. It is far different in 
advanced years, for, though these excrescences possess even then no 
malignant character, they are frequent precursors of epithelioma. 
While it may justly be urged that the early lesions in such cases were 
really epitheliomatous and not verrucous, the fact remains that many 
warty formations of apparently benign character do in advanced years, 
especially when irritated by frequent caustic applications, undergo a 
cancerous metamorphosis. The tuberculous wart also may become the 
source of general tuberculous infection. 


Multiple Cutaneous Tumors accompanied by Intense Pru¬ 
ritus. Under this title Hardaway, of St. Louis, described a rare 
disorder characterized by the occurrence of about sixty pea- to nut¬ 
sized, dense tubercles and tumors covered by a thickened, scaly, and 
excoriated, often hemorrhagic skin. In some situations coalescence 
had occurred, forming thus long and narrow plaques of nearly the 




444 


DISEASES OF THE SKIN. 


width and of half the length of the finger of an adult. The lesions 
were seen upon the outer aspects of the arms and legs, the palms and 
soles, the sides of the fingers, and around the ankles, wrists, and 
elbows. The accompanying pruritus was intense and intolerable; and, 
having lasted for twenty-two years, it was naturally associated with 
the degree of pigmentation often observed under similar conditions. 
The patient, who was an unmarried woman, fifty-one years of age, 
declared that the lesions first appeared as u blisters.” 

Specimens of these tumors, microscopically examined by Heitzmaun, 
exhibited hyperplasia of the epithelial and connective tissues. The 
papillae were longitudinally elongated, branching, and provided with 
narrow capillaries. Numerous nests, greatly varying in size, and con¬ 
taining inflammatory elements with considerably enlarged blood-vessels, 
lay close beneath the papillary layer of the corium. These elements 
showed all stages of transition into basic substance. The deeper layers 
of the derma were built up of very coarse bundles of connective tissue 
and of numerous elastic fibres. 

Synovial Lesions of the Skin. Under this title should be 
described certain strictly cutaneous lesions which possess some impor¬ 
tance from a diagnostic point of view. The author had the opportunity 
of observing these lesions in several individuals, where the exact nature 
of the disorder had not .been understood. They occur in the form of 
wart-like projections from the skin, pseudo-vesicles, and bullae, always 
over the site of bursae connected with tendons, traversing the small 
articulations of the hand and foot. They are seen over the metatarso¬ 
phalangeal articulations; and in the hand most frequently over the 
dorsal face of the articulation between the distal and adjacent phalanges 
of the index-finger and thumb. The first form is that of a roundish, 
corneous, pea-sized wart with a yellowish centre, of long duration, 
usually insensitive unless roughly handled. When punctured there 
exudes a syrupy, yellowish, or grumous fluid, which continues to form 
after repeated puncture. Split-pea-sized vesicles, and bullse as large 
as a silver fifty-cent piece, often exceedingly painful, are also seen, 
especially upon the feet, with simply an epidermic roof-wall. Each 
lesion contains the same thickened, yellowish, or whitish fluid, occa¬ 
sionally mingled with masses like sago-grains. In every case the con¬ 
tents of the lesions are supplied by a synovial bursa beneath the skin, 
with which the lesion is either directly connected, or in communication 
by a short sinus. The treatment requires the complete excision or 
destruction of the secreting cyst-wall. 

Sidney Jones and Makins, of the St. Thomas Hospital, exhibited 
several lesions of this character to the London Pathological Society. 

Papilloma. This term has loosely been applied to a large number 
of cutaneous growths widely differing from each other, both histolog¬ 
ically and clinically. It has been made to include the vegetations of 
syphilis, the neoplasms of neevus, and even the tubercles of lupus. 

The designation, papilloma, is properly limited here to such circum¬ 
scribed hypertrophies of portions of the skin as correspond with warts 


HYPER TR OPHIES. 


445 


in their pathological significance. These growths may be defined as 
excrescences from the cutaneous surface, of a size considerably larger 
than that of any one of the varieties of wart with the exception 
of the condyloma, usually presenting a luxuriant growth composed of 
elongated papillae, blood-vessels, and enlarged rete, covered externally 
with a smooth epidermis like a pellicle, or, more commonly, branched 
and tufted with the cauliflower aspect, and then usually smeared with 
a puriform mucus. The tumor increases rapidly until it attains a 
maximum size, and then indolently persists. Lesions corresponding 
with this description occur in carcinoma, syphilis, and lupus. They 
may develop upon any portion of the body. 

Beigel’s Papilloma Area Elevatum is regarded by Crocker as an 
illustration of the results of the ingestion of one of the bromin salts, 
and this is well corroborated by the picture presented in one of the 
author’s patients where the face was well covered with so-called 
“ papillomatous ” growths, as a result of the administration of the 
salts of iodin. 1 

Papilloma Neuroticum is a term which has been applied to ribbon¬ 
like growths classed by some authors with ichthyosis hystrix. They 
properly belong, however, to the category of verruca congenita. 


NiEVUS PIGMENTOSUS. 

(Lat. ncevus, a mask.) 

(Pigmentary Moles. Ger., Fleckenmal ; Fr. y Tache 

PlGMENTAIRE.) 

Statistical frequency in America, 0 064. 

Nsevus pigmentosus is a congenital, circumscribed pigmentation of the skin, in single 
or multiple deposits, either with or without textural cutaneous change, or asso¬ 
ciated with the development of warts, plaques, tumors, or pilary hypertrophy. 

Abnormal congenital pigmentations of the skin vary in color from 
a light yellow or chocolate-brown to a blackish hue, and they may be 
single, or be multiple and very numerous. They vary in size from 
that of a pin-head to that of tumors of considerable volume; and are 
either ovoid or circular in contour, or are so irregularly shaped as to 
present a fanciful resemblance to parts of the figures of the lower 
animals, whence the popular belief as to their origin in maternal 
impressions. They occur in both sexes, upon the face, neck, trunk, 
thighs, buttocks, and external genitals. The term N^evus Spilus 
is applied to those pigmentations which occur in a smooth and other¬ 
wise unaltered skin; NAivus Verrucosus, to those which are irregular 
aud wart-like; Njevus Pilosus, to those surmounted by a growth 
of shorter or longer, stiff or downy, dark-colored hairs; and 'Njeyxjs 
Mollusciformis, or Lipomatodes, to the soft or firm, more or less 
elevated and projecting tumors. 

i “ Dermatitis Tuberosa, due to the Ingestion of the Iodin Compounds.” Read before the Ameri¬ 
can Dermatological Association, 1888. The Medical News, October 13,1888 ; illustrated with a 
painting in oil. 


446 


DISEASES OF THE SKIN. 


They may be, when multiple, symmetrically or asymmetrically devel¬ 
oped upon the surface of the body; and in either case may exhibit in 
their arrangement the controlling effect of the nervous system. In a 
case reported by the author 1 there were multiple monolateral pigmen¬ 
tary nsevi distributed over the left side of the trunk in the course of 
the intercostal nerves, and in such a manner as strongly to suggest to 
the eye their correspondence in site with the lesions of zoster of the 
same region. De Amicis 2 had previously reported a somewhat similar 
case. Patients with precisely the same lesions are not very rarely 
presented to observation. 

The course of pigmentary nsevi, after attaining their full evolution, 
is to persist unchanged for a lifetime. Their increase in persons of 
tender years is occasionally characterized by a relative rapidity of 
growth. A pilary nsevus upon the cheek of an infant may extend 
over nearly double its original area in the course of two years. 

Lesions of this sort seem to occur with equal frequency in the two 
sexes. It is possible that they may be acquired after birth, as claimed 
by some authors; but it is much more probable that such presumably 
acquired cases are instances of rapid development from minute congen¬ 
ital pigmentary moles. 

A case of unusually large congenital nsevus lipomatodes associated 
with multiple pigmentary nsevi of several forms, occurring in a child, 
was observed by the author in 1883, the report of the case made 
subsequently being illustrated by a chromo-lithograph, 3 which has 
been reproduced among the illustrations of this treatise. 

Pathology. Anatomically, pigmentary moles are readily separable 
into two classes: first, those in which the pigment only of the skin 
undergoes hypertrophy (nsevus spilus); second, those in which both 
epidermis and corium are hypertrophied, forming verrucous, pilous, 
mollusciform, and other lesions. The distinction made by v. Baren- 
sprung, Gerhardt, and others between these two classes and still a 
third, where the lesions are limited to the cutaneous regions sup¬ 
plied by one or several nerves (Nsevus Unius Lateris ; Papilloma 
Neuropathicum) is more apparent than real: for a close study re¬ 
veals a trophoneurotic influence exerted in all cases, even in the 
enormous tumors of a mollusciform type. According to Demi6ville, 
the pigment-accumulation occurs in the corium as well as in the 
epidermis, in the form of ribands stretching along the lines of the 
blood-vessels. 

Treatment. Pigmentary moles very rarely spontaneously disappear. 
Their removal may be accomplished by excision, or by destruction with 
caustics or with the Paquelin knife, or with the needle by electrolysis. 
The last-named method is applicable only to the smaller and more 
superficial growths of this class. Fox 4 calls attention, in connection 
with this subject, to the need of passing the needle no deeper than the 
epidermis, sufficiently deep merely to “ blister the surface of the black 
spot.” 


1 Chicago Med. Journ. and Exam., October, 1877. 2 Lo Sperimentale, March, 1876. 

3 Journal of Cutaneous and Venereal Diseases, July, 1885. 

4 Electricity in Removal of Superfluous Hairs, etc. Detroit, 1886. 


HYPERTR OPHIES. 


447 


Acanthosis Nigricans. 

Under this title Pollitzer and Janovsky 1 describe cases which at 
present it is difficult to recognize as instances of ichthyosis, of ver¬ 
ruca, or of naevus pigmentosus. Morris has since reported a case, 2 and 
Pye-Smith showed a patient before the British Medical Association. 
In these patients the neck, the month, parts of the trunk, genito- 
crural and anal regions, hands, axillae, and thighs, displayed from 
yellow and grayish-brown to almost black pigmented patches, covered 
in some places by fine papillae, some of which were scattered and dis¬ 
crete, while those situated in the axillae, the groins, and the flexure- 
surfaces of the joints, were grouped and coalesced to form papilloma¬ 
tous, vegetating masses. In places there was simple exaggeration of 
the natural lines of the skin, in other parts there were ridges radiating 
from a central point. The mucous surfaces were also involved. Over 
the hands of one patient the color was deepest along the lines of the 
veins; and there was a glassy shimmer to the prominent normal areas 
of the cuticle. In Morris’s case the pigmentation and warty growths 
were not always associated, there being a few sites in which there was 
pigmentation of an otherwise normal skin, or in which there were 
unpigmented warty growths. 

In sections made of the skin removed from one patient there was 
recognized dilatation of the blood-vessels and lymph-spaces in the papil¬ 
lary and subpapillary layers; increase of pigment-cells; enormous 
thickening of papillae and epidermis; elongation and bifurcation of the 
rete-pegs, and some u suggestions” of epithelial pearls. A few colonies 
of bacilli having the shape of short, thick rods were discovered, but 
not in all the secretions examined. 


Xerosis. 

(Gr. tjrjpog, dry.) 

Xerosis is a congenital dryness and roughness of the epidermis accompanied by a 
moderate degree of furfuraceous exfoliation. 

Xerosis, also called “ Xeroderma,” is a term which has been applied 
to the disease sometimes known as Xeroderma pigmentosum, or the 
Melanosis lenticularis progressiva, of Pick. The term has also been 
employed to designate a simple asteatosis, and by some authors has been 
used as practically equivalent to ichthyosis. 

In these pages the term is used to describe a condition included by 
most authors under the title of ichthyosis, which in many cases it really 
is ; but in others the appearance of the integument is to be distin¬ 
guished from that seen in the typical ichthyotic skin. The condition 
to which the name xerosis is here given is really one intermediate 
between keratosis pilaris and ichthyosis simplex. 

1 International Atlas of Rare Skin Diseases, iv., 1890, ii. 

2 Medico-Chirurgical Transactions, vol. lxxvii. 


448 


DISEASES OF THE SKIN. 


Symptoms. The sole symptoms of xerosis are cutaneous. The 
skin of the body, in some regions more than others but at times univer¬ 
sally, is to the touch dry, harsh, rough, and destitute of natural moist¬ 
ure and unguent. Closely inspected the skin-surface is seen to be scaly, 
exfoliation being of the character described as furfuraceous. In some 
cases the hand passed briskly over the surface of such a skin will cause 
a moderate separation of a few of the scales in a scanty shower; in 
other cases, while the surface seems quite fit for the furnishing of such 
free flakes of epidermis, one is surprised to note that such flakes are 
more or less attached, and the clothing of the patient is not, as in 
some forms of psoriatic and pityriasic disease, covered with epidermal 
scales. In brief, there is not in progress a catarrh of the horny layer, 
as in some of the other disorders named; but there is merely an unusual 
keratinic transformation of the elements of that layer. 

The parts chiefly involved are the extremities, more particularly the 
hands, feet, forearms, and legs; but all parts of the skin may be 
involved, including the face, temples, cheeks, and even the lips. 

The disorder is met with in all grades, from the mildest physiolog¬ 
ical dryness of the skin, almost suggestive of the so-called “goose- 
flesh,” to that state in which the exhibition of the face only suggests 
an abnormal condition of the skin. The color of the skin in well- 
marked cases is always of a dirty-yellowish or dirty-brownish shade, 
suggesting the unwashed condition of the integument, and in extreme 
cases of older patients the skin becomes rather deeply pigmented. 
The affection is seen in both sexes and at all ages, being a congenital 
condition the first appearance of which is only clearly indicated after 
variable periods of time after birth. Red-haired individuals perhaps 
furnish the larger number of well-marked cases. The general health 
is unaffected. Before puberty the affection, in northern latitudes, will 
often be inappreciable in summer, and distinct in winter. As maturity 
is reached, however, the condition becomes more or less permanent. 

This disorder is described by some authors as a variety of ichthyosis 
simplex, but the reasons for giving it a separate consideration are that 
the disease does not furnish the typical plate-like scales of ichthyosis; 
and one child affected with what appears at first to be merely xerosis 
may exhibit a typical ichthyosis before puberty, while another will go 
through life, the xerosis of his childhood becoming simply the exag¬ 
gerated xerosis of mature years, but never an ichthyosis. 

Xeroderma may, therefore, be regarded in one sense as a variety of 
ichthyosis, but it cannot be described as a stage of the latter disease. 

The disorder is congenital, and is readily distinguished from all fur¬ 
furaceous scaling diseases of the skin by the absence of inflammation. 

The treatment and prognosis are those of the disease next to be con¬ 
sidered. 


HYPER TR OPHIES. 


449 


ICHTHYOSIS. 

(Gr. 1x6 i)q a fish.) 

(Fish-skin Disease, Xeroderma. Ger ., Fischschuppenaus- 
schlag; Fr., Ichthyose; Ital. , Ittiosi.) 

Statistical frequency in'America, 0.249. 

Ichthyosis is a congenital deformity of the skin, developed first in early infancy 
and manifested in a general scaliness, in the formation of regularly outlined polyg¬ 
onal plates, or in the growth of larger masses of corneous consistency. 

Symptoms. This disorder is one which displays a wide variation in 
its symptoms. To the extremes in either direction two names are 
given, ichthyosis simplex and ichthyosis hystrix. 

Ichthyosis Simplex. The earliest and mildest form of ichthy¬ 
osis simplex is, by many authors, held to be the condition of xerosis, 
fully described in the preceding pages. It will be remembered, how¬ 
ever, that such a xerosis may persist through life without the production 
at any time of the peculiar symptoms of the ichthyotic skin. In these 
earlier manifestations of the disease, then, the skin of the patient can 
merely be described as unusually harsh to the touch, moistureless, and 
covered with adherent or exfoliating, fine scales. The scales are not 
massed, imbricated, nor displayed in plaques, and usually are of a 
dull yellowish-white color. It is rare that the practitioner is consulted 
for the relief of this disorder; it is usually discovered when the skin 
is exposed for other purposes (exploration, vaccination, etc.). In a 
still more advanced degree the scales are massed together, forming 
grayish and whitish, polyhedral elevations or plaques, regularly out¬ 
lined and closely set together, especially upon the extremities and cer¬ 
tain portions of the trunk; elsewhere the scaliness described above may 
be present in a more marked degree. Variations occur, in consequence 
of which the plaques, bordered distinctly by the natural lines and fur¬ 
rows of the skin, are even depressed, centrally or completely, or they 
assume darker shades of color than those described, brownish and 
greenish-brown. 

Ichthyosis Hystrix. With and without the symptoms detailed 
above, the hypertrophy of the skin may, in circumscribed patches or 
larger areas, produce irregularly shaped, verrucous, corneous, cor¬ 
rugated, wrinkled, or rugous masses, usually much darker in color 
than the patches seen in the simple variety of the disease, and more 
often also discovered in adult years. The resemblance is here rather 
to the rough bark of a tree than to the scales of a fish. In other 
still rarer cases the excrescences assume a spinous, acuminate, or 
horn-shaped form. The hand passed over the skin-surface perceives 
not only the excessive roughness, but also the dryness of the skin. 
Perspiration is imperceptible in the parts affected. The nails are 
friable and indurated; the scalp is scaly, and covered with hairs of 

29 


450 


DISEASES OF THE SKIN. 


exceeding harshness. The palms and soles are often spared. Kaposi 
describes certain diffuse callosities occurring in the palmar and plantar 
regions differing from the ichthyotic patches elsewhere. The face is 
usually spared, but, when involved, only the slighter manifestations 
of the disease appear there—minute, superficial, scaly patches of a 
grayish tint. (Fig. 54.) 

Fig. 54. 



Ichthyosis hystrix. (From a photograph.) 


Later studies of the hystrix type of ichthyosis have led to a modi¬ 
fication of the view formerly held. To-day many disorders to which 
the name ichthyosis hystrix was once given are classed with congenital 
warts, psorospermosis follicularis, nsevus unius lateris, and other 
similar affections. 

Ichthyosis is accompanied by insignificant subjective sensations. 
The skin, indeed, of these patients seems inapt for the eczematous and 
other complications of the less diffuse keratoses. In four ichthyotic 
patients who were syphilitic there was a decided tendency to the pro¬ 
duction of les : ons of the mucous surface without cutaneous efflorescence. 


HYPER TR OPHIES. 


451 


The extensor are usually more implicated than the flexor surfaces of 
the extremities. 

Singular variations from the types described above are noted by 
observers. . Hilbert , 1 for example, in a case of congenital circumscribed 
ichthyosis in a young woman, discovered a growth of thick hairs, one 
centimetre long, over the left shoulder and arm. Weisse 2 exhibited 
to the New York Dermatological Society a boy, ten years old, with 
hemorrhagic fissures in an ichthyotic skin, double ectropion, corneous 
opacities, claw-like fingers, attachment of the ears to the sides of the 
head, and a generalized condition of the skin, which became very red 
when warm, some doubt, however, existing as to the diagnosis. 

The most exaggerated types of ichthyosis are seen in the so-called 
u porcupine, 7 ’ “ rhinoceros,” or “hedge-hog” patients. In these 
unfortunate beings the entire skin is converted into a rugged, bristling, 
warty, quilled, or horn-like envelope, suggesting the integument of 
the animals named. Such conditions are represented by Henry Baker’s 
case, described by Anderson. 

The terms, Ichthyosis Serpentina, Nacrea, and Nigricans are em¬ 
ployed to designate those conditions, respectively, in which is recog¬ 
nized a snake-like appearance of the skin, silvery whiteness of the 
scales, or a dark pigmentation. 

Viewing the disorder as thus exhibited in various ways, it is seen 
to be a congenital deformity rather than a disease. It may be partial 
or general, though usually the latter, with intense manifestations over 
the extremities, especially over the extensor aspects, and relative im¬ 
munity of the face, the axillae, the groins, the flexor aspects of the 
limbs, the palms and soles, the glans penis, and the prepuce. 

Like xerosis, the deformity is rarely visible at birth, but usually 
becomes apparent before the completion of the first year of life. It 
is first manifested in the region of election named above— i. e ., over the 
elbows and the knees—and here also, as in xerosis, it may for some 
years only be apparent in northern latitudes in winter, disappearing 
almost wholly in the summer season. In maturity the deformity has 
been known also to disappear temporarily under the influence of inter¬ 
current disease (variola). One patient is said to have regularly cast a 
slough of his integument in the autumn. The general health is usually 
unimpaired. 

Ichthyosis Congenita. (“Harlequin Fcetus.) This exceed¬ 
ingly rare deformity occurs as an intra-uterine modification of the skin 
of the foetus, which is usually brought into the world as a non-via,ble 
monstrosity. The skin is represented by a thick, horny cuirass, deeply 
furrowed, and resembling plates of armor. The ears, eyelids, and lips 
are usually wanting, being replaced by corneous folds suggesting in 
appearance the corresponding features of a mummy. The fingers and 
toes resemble talons and claws. Death usually occurs in the course of 
a few days from both inability to secure nutrition by the act of suck¬ 
ing and from imperfect development of other organs than the skin. 


1 Virchow’s Archiv, September 3,1884, Bd. xcix. 

2 Journal of Cutaneous and Venereal Diseases, 1883, p. 49. 


452 


DISEASES OF THE SKIN . 


Bowen 1 thinks that some of these deformities are due to a persistence 
of the epitrichial layer of the foetus. 

Sherwell 2 describes a case of congenital ichthyosis (so-called “ harle¬ 
quin foetus ”) of unusual interest from the fact that at the time of the 
report the infant had lived to be more than five months old, and seemed 
to be gaining in strength and improving in the condition of the skin. 
No history of heredity or of a family tendency to deformities of the 
skin could be obtained. 

Ichthyosis Linguje (“psoriasis of the tongue”) is a disorder 
described by the French under the title, leucoplasie. It is not a variety 
of ichthyosis. ( Cj Lichen planus of the mucous membranes.) 

Etiology. Ichthyosis is unquestionably a congenital disease, though 
its first manifestations are only apparent during the second year of life. 
It is said to be generally hereditary, but this statement should be 
accepted with some reserve for every individual case. One ichthyotic 
patient married to his own cousin, had by her five children entirely 
free from cutaneous disease. None of his parents or grandparents was 
similarly affected. The disease occurs equally in both sexes, and is 
liable to aggravation in cold climates and the season of winter. The 
general vigor and development of patients thus deformed are, as a 
rule, quite unimpaired. Kaposi says: “The cause appears to be a 
local anomaly of the nutrition of the skin, especially involving its epi¬ 
dermic and fatty elements;” but this scarcely meets the requirements 
of etiology. 

Thost 3 describes ichthyosis occurring in four generations. Accord¬ 
ing to the ascertained genealogy, the ancestor first known to have 
suffered from this affection had five male children who inherited it, 
while one girl and one boy were spared. One of these affected sub¬ 
jects had five children, of whom three males showed the anomaly, 
while one boy and one girl remained free. Another brother, of the 
second generation, had five male and three female children; of these, 
four boys and two girls became affected. One of the latter (of third 
generation) bore four children, of whom three girls inherited the dis¬ 
ease, while the fourth, a boy, escaped. It appeared that the affection 
always showed itself within a few weeks after birth, in the form of a 
roughness of the palmar and plantar surface. With the growth of the 
patient the condition constantly increased in severity, the epidermis 
shedding in large shreds, until the disease reached its maximum by 
the fourteenth year. There was a marked disposition to excessive 
sweating, particularly in the diseased localities; the sensibility of the 
skin remained normal. Microscopic examination showed, in addition 
to hypertrophied papillae, great development of the sweat-glands, 
with marked thickening of the ducts. Treatment failed to give more 
than partial relief. 

In the Molucca Islands and some other isolated regions ichthyosis, 

1 Journal of Cutaneous and Genito-Urinary Diseases. 1895. 

2 Ibid., 1894, p. 385. 

3 Inaug. Diss., Heidelberg, 1880; Centralbl. f. Chir., 1881, No. 10. 


HYPER TR OPHIES. 


453 


on account of its unusual prevalence, has been regarded as an endemic 
affection; but instances of this kind are readily explained, without 
referring to climatic influences, by the operation of the laws of heredity 
with intermarriages. 

Pathology . The diseased, or, better, deformed, skin is found micro¬ 
scopically to be hypertrophied in various degrees according to the devel¬ 
opment of the maiady, the proliferation of its elements occurring in 
connective tissue, papillae, stratum corneum, and blood-vessels. In 
well-marked cases of ichthyosis hystrix the elongated papillae are sur¬ 
mounted by dense cones of the horny layer of the epidermis, more or 
less concentrically disposed, with sclerosis of the connective tissue, and 
a relatively unchanged rete. In the latter particular the dense plaque 
of ichthyosis differs in texture from the wart. 


Fig. 55. 



Ichthyosis hystrix, vertical section : a, masses developed from the stratum corneum ; 6, cones 
formed by the rete ; c, hypertrophied papillae with dilated vessels ; d, dense connective tissue of 
corium, exhibiting numerous vessels transversely divided. (After Kaposi.) 


The polygonal ichthyotic plates are composed for the most part of 
corneous epidermal cells, their long axes parallel with the surface of 
the skin, with an unusual accumulation of pigment-granules between 
the strata. The interpapillary cones are enlarged, the horny layer 
greatly thickened, the hair-follicles indurated,, the papillae elongated 
but not branching, and their blood-vessels dilated. The sebaceous 










454 


DISEASES OF THE SKIN. 


glands are frequently converted into cyst-like bodies, the coil-glands 
distended, and the panniculus adiposns diminished in size. 

SJ! 1 Diagnosis . Ichthyosis not only presents features which are so char¬ 
acteristic as to be unmistakable, but also those which can be well-nigh 
perfectly portrayed in plates. In this respect it differs from a long 
list of cutaneous maladies. 1 

Whenever necessary in the establishment of a diagnosis, aid of an 
important character can be gained in the history of the disease and in 
the entire absence of the lesions and lesion-sequels exhibited in the 
exudative and scaling affections heretofore considered. The most con¬ 
spicuous characteristic of ichthyosis, as distinguished from psoriasis, 
lichen ruber, and pityriasis, is the absence of inflammatory phenomena. 

Treatment. The younger the patient applying for relief, the larger 
are the chances of improvement and of possible recovery. Ichthyosis 
hystrix of mature years is practically incurable. Internal treatment 
is valueless. External treatment is directed to softening, macerating, 
or anointing the skin, and, so far as practicable, in preserving it in a 
softer state. This softening is accomplished by frequent baths, alkaline, 
vaporous, or combined with the use of soap or green soap, and generally 
followed by an anointing with vaselin, dilute glycerin, or lard. The 
French, after the removal of the denser layers of the horny plates by 
the aid of soft-soap and water, anoint the body by friction with the 
glycerolate of starch. Almond, cod-liver, neat’s-foot, and linseed oils, 
or lanolin may be used after the bath. Only by the most assiduous per¬ 
severance is a desirable result obtained and permanently secured. In 
the severer hystrix varieties the most annoying projections and rugosi¬ 
ties may be removed by excision, by the Paquelin knife, or, less pre¬ 
ferably, by the aid of caustics. 

Subcutaneous injections of 1 grain (0.055) of pilocarpin have been 
practised in ichthyosis, in order to induce sweating, with a view to the 
maceration of the skin. Van Harlingen recommends the following 
for use when the epidermis begins to shed after the external application 
of soft soap: 


i£. —Potass iodid., ; 

Adi P pt SbUbUli ’} 

Glycerin., £j; 


1133 

16 

4 


M. 


Anderson recommends the wearing of pure vulcanized India-rubber 
garments, a method of treatment too exhausting for all cases. 

Taking a general survey of the therapeutical management of ichthy¬ 
osis and its results, the course to be advised for the majority of patients 
is very clear. With hut few exceptions, 2 the subjects of this deformity 
are either entirely relieved, or greatly better in hot weather and moist 
atmospheres. Under these circumstances, and having regard to the 
essential fact that the deformity is lifelong in duration, patients should 
always, when practicable, select for permanent residence a climate most 


1 The admirable representation of the ichthyotic skin in Plate F of Duhring’s Atlas is faithful 
in its exactness. 

t While these pages are in preparation the author has been consulted by an intelligent patient 
who positively asserts that her ichthyosis is always aggravated by warm weather. 



HYPER TR OPHIES. 


455 


conducive to the comfort of the skin. There is no step which the 
ichthyotic patient can take at all comparable in value with the impor¬ 
tant selection of a suitable environment. 

Prognosis . Having in view the facts set forth above, it will be 
clear that in no case can a favorable result be anticipated with respect 
to a “ cure ” of the deformity. Treatment, persistent, prolonged, and 
properly directed in connection with suitable climatic influences, may 
do much to improve the condition of the skin. 


ONYCHAUXIS. 


(Gr. 6vv$j, a nail; avtjeo, to grow.) 


Onychauxis, or hypertrophy of the nails, is an abnormal development of these 
appendages of the skin in any diameter. 

Symptoms. This may be a congenital or acquired disorder. The 
nail-substance may be developed to an unusual extent either as an 
idiopathic or a symptomatic affection, and in each case may simply be 
increased in volume, extent, or number, or may exhibit such increase 
in connection with secondary changes. Thus, the nail may develop 
to an extraordinary length or breadth, preserving its general character 
as regards texture, color, and position; or it may also be changed in 
any particular, becoming opaque, discolored, dirty-yellowish, and 
blackish or brownish; rugous, furrowed, horny, and rigid; thickened 
in one part and thin, vitreous, and extremely fragile in another; tilted 
to one side or the other on its bed; or projected backward in recurved, 
irregular lines. Finally the matrix may be inflamed, suppurating, 
hemorrhagic, or the seat of an excruciating pain. One or more of the 
nails may be affected; in some cases the entire twenty are similarly 
involved. 

The diseases in which these changes occur as symptomatic lesions 
are numerous, since it is evident that the matrix, from which the nail 
is produced, would scarcely enjoy immunity in the case of profound 
alteration of the skin in its vicinage. Thus, eczema, lepra, psoriasis, 
lichen ruber, syphilis, scarlatina, perforating disease of the foot, var¬ 
iola, and other diseases, are attended by changes of various grades of 
severity in both matrix and nail. 

The "condition termed Paronychia (Whitlow) is that in which one 
or both lateral borders of the nail bury themselves deeply in the 
tissues adjacent, producing thus an exquisitely tender and painful state 
of the soft parts, which may suppurate or surround the attached limb 
of the nail with exuberant granulations. This condition is more fre¬ 
quently observed in the nails of the toes, as these appendages of the 
skin of the feet are liable to injury from the pressure of ill-fitting 
boots, gaiters, and shoes. In the condition described as Onychia 
the matrix is not only inflamed, but the nail-substance is, as a conse¬ 
quence, texturally changed. No strict line of demarcation, however, 
can be described between the two conditions. The term Onycho- 


456 


DISEASES OF THE SKIN. 


gryphosis has been employed to describe the contorted deformities 
which cause the nail to resemble a claw. 

Onychomycosis is the name given to that condition in which the 
nail substance is invaded by vegetable parasites. In such cases the 
nails become opaque, discolored, and thickened, with a noticeable fria¬ 
bility at the projecting border. 

Syphilitic Onychia is the condition in which one or several of 
the nails may become affected, though it is quite characteristic of the 
disease to exhibit limitation to the extremity of a single digit. In such 
a case there is usually a very marked involvement of the peripheral soft 
parts, which may be infiltrated with gummatous material, though the 
nails may be extensively damaged when the soft parts of the fingers are 
apparently normal. The bullous syphiloderm, among the congenital 
manifestations of the disease, will at times form beneath or quite near 
the nail, thus endangering its integrity. In both forms ulcerative 
results are common, with secretion of a foul discharge. 

In the affection termed “ perforating disease of the foot * 9 all the 
nails of the feet may exhibit a characteristic onychauxis. 

Traumatism (constant or intermittent pressure of shoes) may augment 
the size of the nail in one or another diameter; and the deformed 
talons resulting from gross and long-couticued neglect (East Indian 
devotees, etc.) are illustrations of another type of hyperplasia. Super¬ 
numerary nails may be found on supernumerary fingers and toes; or 
double organs on a single digit; or in unusual situations, as over the 
scapula (Tulpius); or on a digital stump; or in an ovarian cyst. 

With respect to onychauxis proper, two forms are recognized: 
in the first, the nail-cells are more closely set together and the result¬ 
ing hypertrophy is declared, not in changes in bulk of the nail, but in 
a dense, thick, opaque, glossy, grayish-white transformation of the 
organ. The nail is perceptibly increased in weight and becomes so 
solid that it cannot be cut by ordinary implements. It may be also, 
though not changed in bulk, altered in shape, its free border curved 
downward or upward. 

The second form represents a visible hypertrophy in bulk, the nail 
being enlarged in one or several diameters. Enlargement in a trans¬ 
verse diameter necessarily involves the soft parts adjoining. Vertical 
hypertrophy results in any one of the claw- or talon-like forms of 
onychogryhosis. 

Congenital Dystrophy of the Vails and Hair. Vic-olle 
and HaliferS 1 and C. J. White 2 report interesting cases of dystrophic 
disorders of the nails and hair extending through several generations 
of the same family. In the French cases the condition was seen in 
thirty-six individuals in six generations. Oue of those affected was 
an idiot, another a subject of hysteria, and another of feeble intellect. 

1 Ann. de Derm, et de Syph., August and September, 1895. 

2 Journal of Cutaneous and Genito-Urinary Diseases, June, 1896. 


HYPER TR OPHIES. 


457 


There were other evidences of a family tendency to mental and nerv¬ 
ous deterioration. The hairs in the affected individuals were scanty, 
short, thin, light-colored, friable, and easily epilated. The most 
marked changes, however, were in the nails, which showed various 
grades of hypertrophy and atrophy, with periungual changes of an 
inflammatory type, due probably to injury or secondary infection. 

Etiology. Onychauxis may be congenital or acquired, idiopathic 
or symptomatic, and be due to inflammatory changes in the corium or 
matrix of the nail; to traumatism; to defective hygienic care of the 
general surface of the skin, including the nails; and, perhaps, in 
exceptional cases, to senile influences. 

Pathology. According to Geber, in gryphotic nails there is super¬ 
ficially a tolerably uniform consistence; and in the deeper strata a 
harder or softer substance arranged in fan-like layers. In the former 
region the nail is made up of small, roundish, or flattened cells con¬ 
taining variously sized dark granules. These cells have a linear 
arrangement along the longitudinal axis, and, in places, as along the 
higher transverse ridges, are more closely aggregated. Deeper, the 
cells are irregularly grouped. According to Virchow, they con¬ 
tain, centrally, horizontal masses of horn, that descend laterally, 
including the so-called “ medullary spaces.” These spaces are sharply 
defined loculi filled with a homogeneous, lustrous, yellow, or finely 
granular mass; and in them may be found epidermal cells in process 
of. keratinization. 

When the nail is lifted off, its bed looks short, arched, and narrow. 
Beneath the epidermis accumulated upon the surface, the hypertro¬ 
phied ridges, longitudinally arranged anteriorly, and more particularly 
the papillae, become visible, the latter containing large vascular loops 
surrounded by a small-celled infiltration. 

Treatment. The treatment of the disorders of the nail described 
above is largely that of the maladies in which they occur. Arsenic 
and iron are often indicated in these affections, and their influence upon 
the nutrition of the nail cannot be questioned. In syphilitic onychia 
the constitutional treatment of the disease is essential. The cutting, 
scraping, and trimming of the nail by the aid of the useful instruments 
found in the chiropodist’s case, supplied by most surgical instrument- 
makers, are important measures in many patients. 

The treatment of ingrowing toenail varies with the extent of the dis¬ 
ease. In mild cases soft threads of charpie are insinuated between 
the offending border of the nail and the tender surface upon which it 
presses. Counter-pressure by plaster and the local use of the crayon 
of nitrate of silver may be at times employed with advantage. In 
severer cases the nail may be removed, though this is generally unwise. 
The soft parts are, by some surgeons, completely removed from the 
side of the nail by means of a thin-bladed bistoury; and the nail per¬ 
mitted to grow down upon one side of the extremity of the distal 
phalanx, thus protecting the cicatrix and radically preventing the 
recurrence of the disease. 

The proper dressing of the feet in onychauxis of the toes is a matter of 
great importance. The shoes and socks or stockings should be adjusted 


-458 


DISEASES OF THE SKIN. 


both as to texture and shape to the special requirements of each case. 
After the hypertrophied tissue is largely removed by cutting or scrap¬ 
ing, the phalanx may be enveloped in a plaster-mull or salve-muslin 
of diachylon ointment, or with mercurial plaster, and the whole be 
covered with a leather or a rubber cot. 

The prognosis in these disorders of the nails rests entirely upon the 
nature of the malady in which they occur. Idiopathic and localized 
changes, as also those occurring in transient cutaneous diseases (e. < 7 ., 
the exanthemata), often terminate favorably. In severe constitutional 
or grave cutaneous diseases the outlook is less promising. The diseases 
of the nail are usually obstinate and less amenable to treatment than 
the similar affections of the softer parts. In cases where there is con¬ 
genital disease of the nails a prognosis should be made with reserve. 


HYPERTRICHOSIS. 

(Gr. vTcep , in excess; dpi£j } hair.) 

(Hypertrichosis, Hypertrophy of the Hair, Hairiness, 
Hirsuties, Hypertrichiasis, Polytrichia, Trichauxis. 
Ft., Poils accidentels.) 

Statistical frequency in America, 0.416. 

Hypertrichosis is a development of the pilary filaments exaggerated as to size or 
number, or unusual either with respect to the location of the growth, or the age, 
or sex, of the individual in whom it is displayed. 

This anomaly may be congenital, and may occur in various grades. 
It is sufficiently common to see infants at birth provided with extremely 
long hairs on the hairy part of the body, this growth being usually 
replaced later by shorter filaments. Universal congenital hirsuties is 
a rare deformity, the entire body being then covered with longer or 
shorter downy hairs of various colors. 

Acquired hirsuties may be partial or universal, much more com¬ 
monly the former. Thus, the hairs of the scalp or the beard may acquire 
an enormous vigor and length, reaching fully to the ground when the 
figure is in the erect position; or the hypertrophy of the hairs may 
affect the face of the child or the woman, and in this sex either the 
upper lip, chin, cheeks, or all portions of the body usually covered 
by hairs in man, be provided with a vigorously and symmetrically 
developed pilary growth. 

Remarkable instances of universal congenital hirsuties are occasion¬ 
ally observed. The so-called “ Rusian dog-faced man ’ ’ (Andrian Jeft- 
ichjew) and his son, who were lately on exhibition in the United States, 
were noteworthy illustrations of this anomaly. In most cases the influ¬ 
ence of heredity is usually distinct and is often accompanied by defec¬ 
tive dental development, such as entire absence of molar or of canine 
teeth. In all cases of hypertrichosis, whether congenital or acquired, 
the parts normally unprovided with hair, such as the palms, soles, 


HYPER TR OPHIES. 


459 


ungual phalanges, prepuce, glans penis, upper eyelids, and vermilion 
border of the lips, are not the seat of the pilosis. 

As the growth of the beard in man is more or less associated with 
the maturity of the sexual organs, so the hypertrichosis of women 
and children is at times related to a precocious, perverted, or arrested 
function of the generative organs. The reported instances of men¬ 
struation in female infants and children usually include a description 
of abnormal pilary development about prematurely developed pudenda; 
and after the climacteric period, when some women conspicuously in 
external appearance begin to resemble individuals of the opposite sex, 
either isolated, thick, bristle-like hairs develop over the chin or lips, 
or the extreme hirsute condition may be reached. Duhring 1 reported 
one such case, which is illustrated by an excellent lithograph represent¬ 
ing the face of a woman provided with a superb beard. 


Fig. 56. 



The Russian “ Dog-faced Man.” 


The influence of the sexual organs in the hypertrichosis of women 
is well demonstrated in the following case coming under the author’s 
observation. 

A married woman, thirty-three years of age, weighing one hundred 
and fifty pounds, mother of three healthy children, applied, in 1883, 
for relief of a general and facial hirsuties which had resulted in the 
growth of a full beard and moustache. She had not menstruated for 
more than a year, and had been pronounced by an expert to be past 
the climacteric. During 1884 and 1885 the author removed in suc¬ 
cessive operations the hairs of the face by the electrolytic method 
described below. Menstruation began while she was subject to the 
influence of the galvanic current in the operating-chair, and continued 
thereafter irregularly, at times with intense pain and even menorrhagia. 
In 1886, after the last of the operations on the face, she rather sud¬ 
denly lost in weight, decreasing to one hundred pounds, and began to 


i Archives of Dermatology, April, 1877. 


460 


DISEASES OF THE SKIN. 


menstruate regularly and painlessly. The hypertrichosis of the gen¬ 
eral surface then disappeared by a simple fall of hair. In the latter 
part of the year she again conceived, and in March, 1887, being then 
quite free from any form of hirsuties, she brought a healthy male child 
into the world. 

As the result of the local application of stimulating and oily lini¬ 
ments persistently and over a single region of the body (scapula, 
sacrum, sciatic notch, etc.), as also after traumatism by pressure or 
otherwise, a growth of long and numerous hairs is often produced. 
Care should be had in the management of cases of acne and rosacea in 
the persons of dark-skinned young women with luxuriant hair upon 
the head, lest a similar growth be produced upon the chin, cheeks, 
or nose. 

In cases of hypertrichosis the hairs may variously be colored, and 
the hypertrophy of downy hairs purely be numerical, or result in 
increase in the actual size of the shaft of the individual filaments. 
In neither case do the hairs present any anatomical peculiarities of 
structure. The localized congenital form of hirsuties is often charac¬ 
teristic of certain moles, known as Njevi Pilosi. The surface of 
pigmentary moles (Nasvi Pigmentosi) is often very extensively cov¬ 
ered with hairs of a dark color. Singular anomalies have been figured 
by a number of dermatologists where extensive regions (one or several 
limbs, the entire back, even the greater part of the body) were the seat 
of enormous pigmented moles, covered with warts, fibromata, and 
other benign tumors, and clothed with a thick covering of longer or 
shorter hairs. 1 All such cases exhibit a striking development in either 
symmetrically or asymmetrically disposed areas of distribution of 
cutaneous nerves. 

The Hypertrichosis Neurotica, of authors, is that condition in 
which an excessive growth of hair has succeeded spinal paralysis and 
other morbid conditions of the nervous centres. Under the title Tro¬ 
phoneuroses of the Skin in this work are described changes of a similar 
kind, in which there is association of hypertrichosis with hyperidrosis, 
changes in the nails, and even extensive tylosis of the palms and soles. 

Under the name Plica Polonica was formerly described a condi¬ 
tion which was supposed to be a disease peculiar to Poles (whence its 
name), but which has long been recognized as a result merely of per¬ 
sistent neglect, filth, the invasion by parasites, and consequent exuda¬ 
tive disorders of the scalp. When it exists the hairs form a huge 
matted mass on the crown of the head. Hebra devoted some interest¬ 
ing pages to the superstitious awe with which this accumulation of 
hairs, lice, and filth has been regarded. In Alaska a number of cases 
of plica have been observed among the natives of that region. A 
typical case of this curious deformity was lately presented at the 
author’s clinic. 

Under the title Neuropathic Plica, Le Page 2 describes a case in 
which tangled “ lumps ” and “ festoons” of hairs, flat, curled, looped, 

1 See the author’s case of nevus lipoinatodes in a child, the pilary growth being at that age 
undeveloped. Journal of Cutan. and Ven. Diseases, July, 1885. 

2 British Medical Journal, Januarv 26,1884, p. 160. 


HYPER TR OPHIES. 


461 


and intertwined appeared on one side of the head of a girl seventeen 
years old, who had previously suffered from neuralgic pains in the site 
of the growth. 

Etiology. The causes of hypertrichosis are obscure. It is clear that 
whatever determines the blood in excess to any one region of the body 
may indirectly be the cause of hypertrophy of the hair, a fact demon¬ 
strated in patients who, after applying sinapisms or liniments for 
years to the skin over the seat of a rebellious neuralgia, exhibit in 
this region an abundant growth of hair, often several inches in 
length. In women, whose sex renders the anomaly most deforming 
and distressing, it is chiefly noted, as has been observed, in precocious, 
perverted, or arrested activity of the sexual function. The neurotic 
conditions accompanying certain varieties of hirsuties may be inappre¬ 
ciable; or evidently be due to traumatism; or be exhibited in paralyses, 
muscular atrophy, etc. It may be a racial peculiarity, a family trait, 
an inherited anomaly, or an epiphenomenon in dwarfs, monsters, indi¬ 
viduals affected with club-foot, insanity, and congenital deformities of 
several kinds. 

Treatment. To Hardaway, of St. Louis, Americans are indebted 
for the popularization of the method of removing superfluous hairs by 
electrolysis, first devised by Michel, of his city. After him most 
American dermatologists have successfully removed extensive pilary 
growths without subsequent reproduction of the hairs. A fine needle is 
introduced into the hair-follicle and pushed well down to the papilla 
at its base. This instrument is connected with the negative pole of a 
galvanic battery containing six or more elements, the positive pole of 
which is in connection with a sponge-electrode held in the patient’s 
hand, who is thus enabled to make or break the circuit at will. When 
the current is passed a few minute bubbles of gas escape from the 
orifice of the follicle, and, when the hair-papilla is destroyed, the hair 
itself is readily extracted. The dexterity acquired by practice is requi¬ 
site for the proper performance of the operation, with a view particu¬ 
larly to the insertion of the needle at the proper angle into the follicle. 
Few patients complain of pain. The number of hairs removed at a 
sitting varies with tbe sensitiveness of the patient’s skin. The result¬ 
ing scar is quite imperceptible or far less disfiguring than the hirsuties, 
suggesting the appearance of the male beard after shaving. Transitory 
macules, papules, pustules, and wheals occur at the site of puncture. 
Care should be taken not to insert the needle too deeply in the partic¬ 
ularly vascular regions of the face, as an aneurysmal tumor might be 
produced as a consequence. 

Every detail of this exceedingly simple operation has now been 
carefully studied by American operators, and the results, as confirmed 
by the author’s experience, may be given as follows: 

1 . As to the battery, any good galvanic battery may be employed. 
The author uses habitually a forty-cell stationary battery, whose switch¬ 
board is so arranged that" any number of selected cells may be brought 
into the circuit. A galvanometer should be placed in the circuit indi¬ 
cating a current of from one to four milliamperes. The number of cells 
employed should be different for different individuals, different parts of 


462 


DISEASES OF THE SKIN. 


the face, and on different days with the same individual— e.g ., a smaller 
number is required when a patient previously operated upon returns 
after a somewhat long period of rest. Two to four cells only may be 
tolerated over the tip of the nose or the upper lip near the septum nasi. 
Twelve to twenty may be well borne, after some experimenting, on an 
insensitive chin. 

2. The best needle is a carefully selected, exceedingly fine jeweller’s 
broach, its shaft and point being annealed by rapid passage through 
the flame of an alcohol lamp. It is often useful to have the point also 
well rounded on an emery-wheel. The irido-platinum needles are 
useful, but inferior for general work to the well-annealed, carefully 
selected broach. 

3. The needle-holder should be simply a convenient insulated handle, 
sufficiently long to protect all the points of the operator’s right hand 
from the current. The author employs Prof. White’s long handle. 
Duhring’s 1 holder, which is of the shape of a thin lead-pencil or pen¬ 
holder, is about four inches in length. The handle, or stem, is of 
hard rubber, through which passes a metallic rod, acting as a conductor 
for the transmission of the current. The needle is inserted into the 
needle-holder proper, which is slotted, the needle being clamped im¬ 
movably by means of a screw-nut. In the other end of the stem there 
is an insulated inserting-pin attached to the cord leading to the battery. 
The instrument is of proper weight, convenient to handle, and alto¬ 
gether well adapted for the operation. 

4. The patient should be seated or reclining at ease in a good light, 
with the handle of the electrode connected with the positive pole of 
the battery in one hand, ready to press the sponge into the palm of 
the other. In this way, at the bidding of the operator, the patient 
connects and breaks the circuit at will. The sponge attached to the 
holder should be wet with a solution of salt and water. 

5. As to further details of the operation it is well (a) to make the 
connection only after the needle is in situ ; ( b ) to introduce the needle 
with a gentle manipulation (acquired only by skill and well charac¬ 
terized by Hardaway as a u catheterization” of the hair-follicle), ob¬ 
serving a certain degree of parallelism with the hair-shaft as the needle 
enters; (c) to operate leisurely, making sure that the current is not 
broken by the separation of the hands of the patient, before the hair 
is completely free in the follicle. This last can be ascertained by 
gentle traction on the shaft in from twenty to forty seconds after the 
insertion of the needle; (d) to operate in succession upon contiguous 
hairs when practicable, not selecting one here and one there, the latter 
course being productive of greater pain; (e) never to use the positive 
pole in connection with the needle, an error which results in the pro¬ 
duction of uusightly pigmented blemishes on the surface of the skin. 

The previous employment of preparations of cocain both hypoder- 
matically and by inunction— e.g., the oleate of cocain—to relieve or 
diminish the pain of the operation, may be followed by exceedingly 
unpleasant consequences. The author has seen a dermatitis, thus 
induced, persist for months. 


American Journal of the Medical Sciences, July, 1881. 


H YPER TR 0 P HIES. 


463 


Prince, of Boston, 1 lays stress upon the accurate regulation of the 
current by the aid of the absolute galvanometer, which the author has 
found in his practice useful but not essential. Fox, 2 of New York, reports 
a gradual decrease in the number of hairs returning after operation, 
proportioned to the improvement in the instruments and the skill of 
the operator. There can be no question that the percentage of such 
returns varies with these conditions. 

All patients affected with hirsuties are not to be advised the opera¬ 
tion. The author has declined to operate in many cases which were 
not deemed to belong to the class in which the best results of the 
operation may be expected. Young and vigorous women, usually 
unmarried, may point out hairs to be removed that are merely full- 
developed filaments of a thick downy growth, all the hairs of which 
are rapidly pushing to equal maturity. Here the operation itself, 
by inducing hyperemia of the skin, may simply hasten the hyper¬ 
trichosis actually in progress, and thus aggravate the disorder. In 
most cases, when an operation is undertaken, both parties should fully 
uuderstaud the possible issue. It may also be a question whether 
it lies within the legitimate sphere of the physician to remove super¬ 
fluous hairs from the habitually covered breasts and arms of women. 
This operation has unfortunately found its way into the hands of 
the unprincipled and the ignorant, who, in their efforts to extract 
money from the credulous, have in some of the larger cities brought 
the operation into poor repute. It is, however, all that can be desired 
if only it be performed by one with sufficient skill and strict consci¬ 
entiousness, for if hairs are rapidly plucked away from their follicles 
while an electric current is merely passing, the return of each filament 
is prompt and mortifying to the patient. It should, therefore, be well 
understood to be a procedure requiring ample time on the part of the 
operator, and either remarkably good vision or eyes aided by a mounted 
lens. Not more than from forty to sixty hairs can be removed in an 
hour by an expert operator; and there are few who can work with 
advantage more than one hour at a sitting, or more than one or at 
most two hours in a day. 

Hairy nsevi are best removed by complete excision. 

Depilatories for the removal of superfluous hairs operate by the 
destruction of the filament without obliteration of the papilla. The 
consequence is that the hairs are reproduced in the course of about a 
fortnight. Most of the compounds used for this purpose contain either 
the sulphate of calcium, sulphate of arsenic, or sulphide of barium, 
made into a species of paste with warm water. This paste is applied 
over the hairy surface with a spatula, and is permitted to remain until 
it dries, or produces a sensation of heat or burning, a period usually re¬ 
quiring ten minutes. It is then rapidly removed by scraping with the 
spatula, and the surface thoroughly cleansed with warm water, after 
which the skin is anointed with cold cream, or other similar unguent. 

Of these depilatories Duhring recommends the following: 

1 The Exact Measurement of the Electric Current, and other Practical Points in the Destruction 
of Hair by Electrolysis. 

2 The Use of Electricity in the Removal of Superfluous Hair, etc. Detroit, 1886. 


464 


DISEASES OF THE SKIN. 


8 

12 


R.—Barii sulpliidi, 



3ij; 

aa ^iij; 


M. 


1 UAV * tXllljL.y ) 

To be prepared in form of an impalpable powder, which, just before using, is 
to be mixed with water to form a thin paste. 


The following are formulae devised by French authors: 


R.—Sodii sulphat, 


Calcis, 

Amyli pulv., 


aa ^x; 


3 iff 


12 

40 


M. 


To be finely triturated, and, when used, to be made into a thin paste with 
water. (Boudet) 


4 

6 

32 


3j; 

3j ss ; 

|j; 


R.—Calcis, 


Sodii carbon, 
Cerat. adipis, 


M. 


To be applied as a depilatory in the manner of a paste. 

All these formulae require caution in their use, and they should never 
be intrusted to unprofessional hands. 

Shaving may be practised upon the hirsute face of women, and, 
with a similar end in view, also epilation; the latter, particularly in 
cases of hypertrophy of the hair, limited in extent. Partial success 
has attended the thrusting into the follicles of needles previously dipped 
in various caustic solutions, or heated in various degrees, but these 
methods are all far inferior to electrolytic destruction of the hair-papilla. 

3. HYPERTROPHIES OF CONNECTIVE TISSUE. 

(EDEMA NEONATORUM. 

(Edema of the newborn is characterized by the occurrence of an 
indurated tumefaction of the skin, most noticeable in the lower extrem¬ 
ities of infants affected with impaired circulation. 

(Edema and sclerema of the newborn have long been confused. The 
distinction between them was first well established in 1877, when 
Parrot, under the title Athrepsie , first described with clearness the 
morbid condition now recognized as oedema neonatorum. 

Symptoms. The disease, which is of exceedingly rare occurrence in 
America, is observed in infants prematurely brought iuto the world, 
or at term, and of feeble vitality. On from the first to the third day 
after birth the child is found to be drowsy and difficult to waken, with 
the posterior and other parts of the thighs and legs, the hands, and 
the genital organs pallid, cold, livid, and retaiuing the impress of the 
finger as do oedematous tissues in general. At this point recovery may 
ensue, but in severe cases the oedema spreads, always more marked iu 
the lower portions of the body, as a result of gravity, the skin becom¬ 
ing violaceous red, deep yellowish, or dirty looking. As the disease 
advances the integument is more and more difficult of identification. 
Meanwhile the little patient becomes more drowsy, its respirations 
fewer, its cry weaker, and its temperature lower. Death may ensue 
from a pulmonary complication, from diarrhea, or from any inter¬ 
current disorder. Usually the child passes into a state of coma. 
When recovery ensues the oedema becomes less marked, and the 





HYPER TR OPHIES. 


465 


indurated skin more and more impressible. A few days, in satisfac¬ 
torily managed cases, suffice to restore the patient to a condition of 
health. In some instances the oedema begins in other portions of the 
body than those named; and in others there is a marked febrile reac¬ 
tion. 

Etiology. The recognized causes of the malady are prematurity of 
birth, exposure to severe cold soon after birth, poor hygiene, atelectasis 
of the lungs, and inability to take the nipple. 

Pathology. Venous thrombosis, resulting in the effusion of serum 
into subcutaneous tissue, is a consequence of the enfeebled action of 
the heart. The fat, on excision, is found to be particularly dense and 
yellowish. 

Diagnosis. The distinction between oedema and sclerema neona¬ 
torum is not made without some difficulty, the disorders greatly resem¬ 
bling each other. In sclerema the joints, and particularly the jaws, 
are immobile; the disease is apt to be generalized; the firmness of the 
integument is greater; and there is no tendency to an oedema chiefly 
marked in dependent parts of the body, as over the lower limbs. 
The color of the skin in the two disorders may be nearly the same. 
The pitting on pressure of the swollen skin is highly characteristic of 
oedema neonatorum. Scleroderma does not occur in children before 
the close of the first year. 

The 'prognosis is grave; but with good treatment recovery may occur 
when the oedema is not generalized. 

The treatment is that of scleroderma neonatorum. 


ACUTE CIRCUMSCRIBED (EDEMA OF THE SKIN. 

(Angioneukotic (Edema.) 

This disorder, which has been described chiefly by Quincke, Riehl, 1 
Milton, Striibings, Rapin, and a few other observers, 2 is characterized 
by the occurrence in successive and recurrent attacks, very rarely per¬ 
sistent in character, of circumscribed, oedematous, infiltrated and non¬ 
pruritic plaques, developing with acute symptoms and as rapidly 
disappearing. The surface of the affected area is commonly reddened 
in various shades, from a light rosy hue to a livid red. The plaques 
vary in size from that of a small coin to that of the section of a large 
orange, and may even considerably surpass these dimensions. The 
cellular tissue of the skin and mucous membranes is chiefly involved; 
but the papillary portion of the corium is also largely concerned in the 
morbid process, as is also the superior vascular plexus of the pars papil¬ 
laris. Though as a rule no itching is awakened, the elevated disk 
may be the seat of a sensation of considerable burning or tension. 

Though each individual outbreak may be rapid of occurrence, the 
disorder responsible for the cutaueous symptoms is unquestionably 
chronic in duration; and it is the successive and repeated expression 


1 Wien. med. Presse, 1888, No. 11. 

2 Cf. Courtois-Suifit (Annal. de Derm, et de Syph., 1889, p. 859). 

30 


466 


DISEASES OF THE SKIN. 


of its influence upon the skin, that in rare cases produces a more or 
less persistent and obstinate cutaneous oedema limited to one portion 
only of the integument. 

The lesions occur upon the conjunctiva, the pharynx, the larynx 
(where severe obstructive consequences may result), and also as facial 
symptoms, especially upon the eyelids and the lips. The lesions are 
to be recognized also upon the penis, the scrotum, and the vulva. The 
persistent oedema, described later and attributed to recurrent attacks of 
erysipelas and lymphangitis, is not of this class. 

Diagnosis. The disorder should not be confused with erythema 
multiforme, erythema nodosum, giant urticaria, syphilitic and rheu¬ 
matic nodes, nor with pseudo-lipomas. Between some of these affections, 
especially the three first named, no precise limits can be drawn, and 
the diagnosis must be made largely from the concomitant symptoms 
and from the absence, in circumscribed oedema, of itching or pricking 
sensations, febrile complications, and rheumatoid pains. 

Treatment. Circumscribed oedema is produced under the influence 
of the trophic and vaso-motor nerves; it is, hence, amenable chiefly to 
those remedial agents which tend to influence favorably the nervous 
centres. Internally ergot, iron, nux vomica, quinin, and the sodic 
salicylates are indicated. Diuretics, sudorilics, and cathartics are 
recommended by Besnier and Doyon. The local treatment is largely 
that of urticaria. The author has generally ordered with advantage 
in these cases salt and water over the region of the spine, applied by 
the hands of a competent nurse. The salt is moistened with cold or 
slightly warmed water, according to the constitution and temperament 
of the patient, and is then briskly rubbed with a firm hand over the 
entire spinal region. The back is then sponged for several minutes 
with pure water, at first hot and gradually cooled until the surface is 
well reddened, when, lastly, the surface is dried and the patient made 
to take moderate exercise. The result in many cases is brilliantly 
satisfactory. It is not to be forgotten that in many of these patients, 
especially women, mental anxiety and distress, as in chronic urticaria, 
are responsible for a great part of the trouble. 

Circumscribed and persistent oedema of a single member or 
region of the body, not of the class of successive and repeated swellings 
noted above, is properly considered with the early stages of elephan¬ 
tiasis. It results most often from a localized lymphangitis or so-called 
‘“recurrent erysipelas” (chronic eczema of the face, tumefaction of 
nose and cheeks, due to obstruction by tumors of the antrum of High- 
more), and appears upon the face usually as a smooth, shining, whitish 
or reddish tumefaction, ill-defined as a rule, in a few cases with fairly 
good definition. The swelling is usually of firm consistence, but can 
with some pressure be indented with the finger. It is said to be always 
the seat of passive hyperemia, never of active inflammation; but this 
statement should be accepted with some reserve, as in the case of 
smokers of tobacco and hard drinkers an active inflammation is some¬ 
times awakened. These patches are rarely painful or tender; one is 
usually consulted with a view to the relief of the consequent moderate 


H YPER TR OP HIES. 


467 


deformity. They occur as well upon the lower limbs and breasts of 
women. 

The treatment of these cases is by frequent shampooings and em¬ 
brocations, to stimulate the absorbents, aided by elastic compression. 
Facial deformities of this class are always benefited by abstention from 
the use of tobacco and alcoholic stimulants, the diet at the same time 
being carefully regulated. The nasal cavity, the region of the orbit, 
and the mouth (caries of the teeth, etc.), should always be examined 
with a view to the removal of the cause. 


SCLEREMA NEONATORUM. 

(Gr. ouXTjpdg, hard; veov, lately; yewau, to bring forth.) 

(Scleroderma Neonatorum. Fr. y Sclereme des Nouveau-nes.) 

Sclerema neonatorum is a disease recognized at birth or in early infancy, and is 
characterized by coldness and induration of the skin and immobility of the body. 

This disease is not to be confused with oedema neonatorum, from 
which it is wholly distinct in character. 

Symptoms. At birth, or between the second and the tenth day after, 
the lower limbs of the child assume a livid or whitish-yellow appear¬ 
ance, occasionally suggesting the hue of wax; and they become of a 
leathery consistency. This condition spreads gradually over the lum¬ 
bar region, the dorsum of the body, and the chest in front and behind, 
and, in the course of a few days, may involve the entire integument. 
When pressed upon with the finger, the skin produces the impression 
of half-frozen tissue; the face suggests a cold and rigid mask; the 
thighs in their sockets and the arms in the shoulder-joints are immobile. 
Usually there is somewhat less firmness of the abdominal integument. 
The taking of the Dipple, deglutition, and even the opening of the oral 
labial orifice, are affected only with great difficulty, and eventually 
become impossible. The respirations are shallow and imperceptible; 
the pulse, in well-marked cases, is imperceptible at the wrist; and the 
thermometer in the rectum is not raised to the lowest register of the 
ordinary clinical instrument. There is often no cry. 

There may be a coincident icterus; and often sprue has been observed 
in the mouth before the declaration of well-marked symptoms. The 
congenital patients are often stillborn. The majority of all subjects of 
the disease perish before the ninth day. 

Etiology. The immediate cause of the malady is retardation of the 
circulation in the cutaneous capillaries, and this may depend upon 
prior disease (pleuro-pneumonia, intestinal disorders) or to conditions 
operating before or at birth (congenital syphilis, feeble vitality). 

Pathology. Ballantyne has observed a small-cell growth in the 
corium, of perivascular situation; Langer ascribes the condition to ex¬ 
cess of fatty acids in infants as compared with adults, with the result of 
producing a fat-consolidation. In Northrop’s cases 1 no fluid escaped on 


i Archives of Paediatrics, vol. vii. 1890. 


468 


DISEASES OF THE SKIN. 


section of the tissues, which were as semisolid as if frozen; scattered 
hemorrhages involved the alveoli, connective tissue, and lymph-spaces 
of the lungs, but there was no collapse. According to Ballantyne, the 
disease is due to overgrowth of connective tissue leading to atrophy of 
the fat-cells and dependent upon a trophoneurosis. Parrot recognized 
the fact that the connective-tissue trabeculae were more numerous and 
thicker than in other cases. 

The treatment of both oedema and sclerema neonatorum is by elevating 
the body-temperature (in an incubator, wrapping the entire body in 
wool, warm-water baths, etc.) and by improving the nutrition in every 
possible way (sterilized milk and stimulants by the stomach-pump, 
through nose, or pharynx). The body may also be well rubbed with 
warmed oil or camphorated alcohol. Brocq suggests friction with 
the warm hand from below upward. 

SCLERODERMA. 

(Gr. OKlrjpdq, hard; dippa, the skin.) 

(Hide-bound Skin, Dermatosclerosis, Chorionitis, Scleriasis, 

Sclerema Adultorum. Ger., Hautsclerem ; Fr., Sclero- 

DERMIE.) 

Statistical frequency in America, 0.030. 

Scleroderma is a chronic affection, characterized by a circumscribed or relatively 
diffuse induration, rigidity, fixation, and subsequent atrophy of the skin, the 
affected parts being yellowish-white, waxy, or pigmented in color, and either 
elevated or depressed, the morbid process enduring for a series of years, and, in 
certain cases, terminating fatally after the induction of marasmus. 

[A] Diffuse Symmetrical Scleroderma. 

The skin symptoms of the disease may be preceded by prodromic 
pains of a rheumatismal character, or by singular cutaneous sensations 
(pricking, tingling, formication), or by muscular cramps, and neurotic 
sensations. In some instances, also, there are vesicles, blebs, scales, 
local hyperidroses, or losses of sensibility in the skin which is about 
to become the seat of the eruption. 

With and without these prodromic features the skin, chiefly of the 
upper portion of the body, becomes symmetrically involved in an 
obscurely defined oedema of a firm character, involving the subcuta¬ 
neous tissue, and at first pitting under strong pressure with the finger, 
but later becoming as indurated and tense as hard leather. The integu¬ 
ment is usually exceedingly difficult to pick up between the finger and 
thumb, and is shining, smooth, waxy, or of alabaster-like hue; in 
other cases it is of a dirty, yellowish, grayish shade. This is the stage 
of infiltration, and, when pronounced, it is not to be mistaken for any 
other condition. The face is then, both to the eye and the finger, mask¬ 
like, immobile in features, and expressionless. The lips are opened with 
difficulty; the lids, though similarly stiffened, are much less severely 
involved; the back of the neck is firm; the chest, shoulders, and 


HYPERTR OPHIES. 


469 


arms are either immobile or are movable with difficulty; the ribs are 
bound down so firmly by the cuirass of leathery integument that 
respiration may be impeded seriously. The temperature is not changed, 
and the sweat may or may not be exuded over the affected areas. The 
abdominal surface is relatively spared. This condition may come on 
very insidiously, and may require months or years for its full evolu¬ 
tion; at other times the progress is rapid, and the evolution is even 
subacute in type. Often the upper extremities are so involved that the 
fingers resemble curved talons; the wrists lose their flexibility, the 
forearms their usefulness. So extreme is the helplessness of some 
patients that they require to be dressed, washed, and fed, even when 
able to travel with relative comfort. 

The lesions are accompanied at times by other subacute disorders, 
such as subcutaneous tubercles, eczema, erysipelas, canities, anidrosis, 
zoster, and acne. 

In the later or atrophic stage of the affection the most pronounced 
of the symptoms are, like the oedematous or infiltrative stage preced¬ 
ing, symmetrical and more extensively declared on the upper segment 
of the body; but the area of the contractured part is generally less than 
that of the tumid integument. The skin becomes then more and more 
tightly stretched and thinued over the underlying structures, and it is 
no longer possible, as before, to draw the finger over the surface, leav¬ 
ing a yellowish-white tracing of its route that disappears as the circu¬ 
lation slowly returns along the line. When this is extreme the skin 
becomes dry, scaling, fissured, or even ulcerated; the muscles may 
considerably waste, thus reducing a limb several inches in circumfer¬ 
ence; the teeth may fall; the fingers permanently be flexed into the 
palm, or the forearm on the arm. When the condition becotnes to 
this extent grave, the patient, who before seemed to enjoy a fair degree 
of health, suddenly exhibits rheumatoid pains, neuralgias, or other 
signs of constitutional impairment, and intercurrent visceral disorders 
gradually bring on a marasmus which in some of the reported cases 
has ended fatally with renal, cardiac, or pulmonary symptoms. 


[B] Circumscribed Scleroderma. 

(Morphea (Gr. fJ.op<pr), a blotch); Keloid [of Addison].) 

Circumscribed scleroderma, or morphea, is characterized by the occur¬ 
rence of one or of several discrete, well-defined, firm, and smooth 
points, patches, lines, or bands, that are often slightly elevated or 
depressed, and surrounded by a delicate violaceous or lilac-tinted halo, 
the involution of which may be followed by macular, punctate, or 
striate atrophy of the skin. 

This form of scleroderma was once held to be rare. It is, however, 
more commonly under the observation of the expert than is usually 
believed. French authors distinguish between the variety displayed 
in plaques and that occurring in bands. Some forms of the latter 
variety are better described as linese atrophicse. 


470 


DISEASES OF THE SKIN . 


Symptoms . The patches of morphea commonly begin as rosy or 
violaceous macules, which irregularly extend in area from nail-sized to 
larger patches, either with relative rapidity or with slowness. In a 
variable period of time the centre of each patch becomes whitish, while 
the peripheral portions of the plaque retain their peculiar shade of 
color. There is thus formed a roundish or oval or irregularly outlined 
area, rarely larger than that of a dinner-plate, with a central portion 
somewhat elevated, infiltrated and “ lardaceous” or flattish, and near 
the level of the adjacent skin. The blanched centre has often the hue 
of old ivory; later, this may be commingled irregularly with a flat¬ 
tened streak or band, distinguished with difficulty from scar-tissue. 
These patches may be single or multiple; in the latter event they 
are arranged, as a rule, along the line of distribution of the cutaneous 
nerves of the trunk, along the inner face of the thigh, more often on 
the lower than over the upper extremities, and asymmetrical in the 
most of cases. When the tissue is pinched between the thumb and 
finger it at first produces the impression of stiffness and hardness; in 
the later stages of the disease the skin may be so atrophied over the 
region involved that it is impossible to make this test. The surface is 
dry and smooth, or, when very carefully inspected, is seen to be trav¬ 
ersed by exceedingly delicate lines. In some instances the plaque is 
dotted pretty regularly with depressed points resembling the patulous 
orifices of sebaceous glands of the face in certain cases of acne, the 
slightly discolored minute, funnel-shaped orifices contrasting thus with 
the dead-white hue of the patch. In other cases this appearance of 
dotting or picking out of the surface is more conspicuous at one part 
than another, being, for example, well shown at an advancing border, 
with a dead-white, depressed centre, or at both extremities of a long 
oval. 

The border of typical patches is highly characteristic. It is made 
up usually of a narrow zone having a pinkish, lilac-tinted, or violaceous 
hue, which, when closely viewed, is seen to be constituted of a fine 
plexus of vessels. This zone may be wanting wholly, as is well shown 
in some cases where the temple is involved; this border may further 
be present in such degree as to be fully as conspicuous as the whitish 
central area. In a patient presenting a palm-sized patch over the 
sacrum, together with a few multiple spots on the side of the neck (a 
portrait of the same having been made in oil), the flame-like, violet- 
shaded areola extended for several inches on one side away from the 
disk, and one of the larger vessels of which it was constituted was 
distinguishable at a distance of several feet from the patient. Purplish, 
and even blackish, hues have at times been recognized in the halo by 
other observers. 

As a rule, there are few subjective phenomena; in some cases itch¬ 
ing, tingling, pricking, and other sensations are experienced. The 
variations observed in this affection are as numerous as they are strik¬ 
ing. The disease may be extensive or may be limited to one or a few 
very small spots. The names: maculosa, nigra, lardacea, alba, plana, 
atrophica, etc., are merely descriptive of clinical features, and are 
rapidly becoming obsolete. 










/ 







MO RPHCEA, after a Portrait in Oil of one of the Author's Patiehts 









HYPER TR OPHIES. 


471 


Between the several types of scleroderma noted above are to be 
found instances which it is difficult to assign to the one class or the 
other. Some are mixed forms in which diffuse scleroderma is devel¬ 
oped in one part of the body and a circumscribed form in another; in 
other cases morphea plaques have developed to generalized symmet¬ 
rical scleroderma. As a rule, the symmetrical forms are developed 
most extensively over the upper part of the body; while the more 
frequent unilateral plaques of morphea occur in greater proportion 
upon the lower limbs. Often the symptoms of the disease resemble at 
the outset those described in oedema neonatorum, with pitting of an 
oedematous surface under pressure. The greatest variation has been 
noted as regards the presence, absence, or exaggeration of sensibility. 
Sweat and sebum may or may not be secreted from the affected patches. 

In the generalized forms, whether symmetrical or not, there may 
occur serious complications from visceral disease (cardiac, vascular, 
or renal complications) due in part to interference with the normal 
function of large areas of the skin. In some cases the mucous surfaces 
are involved. In other cases there is strong reason to believe that 
there are organic changes in the viscera, as well as sympathetic disturb¬ 
ance of function. Some of the visceral muscles have been recognized 
as involved in scleroderma. 

Occasionally the patches are symmetrical. According to Besnier and 
Doyon, pigmentation is one of the most important among the complexus 
of sclerodermatous symptoms. Apart from the pigmented dots visible 
over the sclerosed patches, there often exists over the regions not yet 
affected a species of chloasma in the form of bronzing, diffuse or in 
irregular islets, over the neck, shoulders, and elsewhere. These pig¬ 
mentations are often interspersed with whitish patches of vitiligo. 

The course of circumscribed scleroderma is either chronic, lasting 
for from one to ten years or more; or subacute, with evolution accom¬ 
plished in a few days and an almost rapid involution; or atrophy may 
slowly or rapidly follow, with extreme tension, resulting even in the 
production of attachments to periosteum, or in severe cases in muscular 
atrophy and deformity due to the resulting contracture. In a few 
instances ulceration has ensued. In yet other cases absorption of the 
material constituting the plaque is effected without sequels of any sort, 
few, if any, traces of the process remaining. 

The band-form of circumscribed scleroderma usually occurs in rib¬ 
bon-shaped elongations stretching along a limb in its longitudinal axis, 
or over one-half of the face. Most of these cases are distinguished by 
the occurrence of either an elevated ridge or furrow, or (what is not 
very rare) an elevated ridge with a furrow on one side. The median 
line of the forehead is the commoner site of this anomaly on the face; 
over the trunk it is best displayed on the breast. As noted above, some 
of the cases collated in this category are instances of linese atrophicse. 

Finlayson 1 observed in one case of scleroderma symmetrical gan¬ 
grene of the extremities, a complication related doubtless to the “ sym¬ 
metrical asphyxia of the extremities” described by a number of English 

i Medical Chronicle, January, 1886. 


472 


DISEASES OF THE SKIN. 


authors. The so-called “ glossy fingers” and “ sclerodactylie” of 
symmetrical distribution may belong to the same category. 

The exaggerated forms of the disease noted by several authors, 
where, to a varying extent, the surface of the lateral half of the face 
has been involved, have been described as Hemiatrophia Facialis. 
Here not only the subcutaneous tissue, but the aponeuroses, periosteum, 
and bones may participate in the atrophy, a fact well illustrated in the 
case of Robinson’s patient. 1 In this instance there was also a distinct 
sclerodermatous lesion on the face of one thigh. 

Etiology of Scleroderma. About three-fourths of all cases occur in 
women. The young and middle-aged are generally the victims of 
the disorder, though cases are reported between the first year of life 
and advanced age. Unquestionably the predisposing causes of the 
affection are: rheumatism and the climatic changes to which rheu¬ 
matism is most often attributed; all neurotic states due to emotional 
influences, grief, anxiety, etc.; traumatisms by friction, blows, and 
direct injuries of nerves; blisters; exposures to the direct action of the 
sun; and obscure disturbances of the nervous centre that are difficult 
to appreciate. In one case, a young woman with a series of cir¬ 
cumscribed patches along the inner face of the right thigh, could 
scarcely endure the fatigue of exposure of the part while an oil paint¬ 
ing was made of the disks; yet another case was that of a muscular 
and hardy blacksmith, who exhibited one of the largest plaques of 
morphea over the trunk. 

The etiological importance of the nervous system is, in the explana¬ 
tion of many cases, too obvious to require demonstration. This fact is 
much more distinct in the localized manifestations of the disorder, where 
a region supplied by a single nerve or traversed by a nervous trunk, 
is solely involved. Harley, Sehwimmer, and others have recognized 
cardiac and gastric disturbances; Westphal and Eulenberg, central 
and peripheral changes in the nervous system; Heller demonstrated in 
one case a closure of the thoracic duct. Bancroft 2 repeatedly recog¬ 
nized filarise in large numbers in the blood of a young girl in Australia 
who was affected with a characteristic scleroderma. 

Pathology. The confusion which has existed in relation to the 
question of the identity of scleroderma and morphea is due to various 
causes. By several authors similar symptoms are described under each 
of the two names; and the symptoms described as peculiar to each are 
occasionally seen either simultaneously or successively in the same 
individual. 

Microscopical examination of the structures involved in the disease 
has proved unsatisfactory. The connective tissue of the skin has been 
found, according to Kaposi, condensed and thickened; its elastic fibres 
multiplied at the expense of the panniculus adiposus; its muscular 
tissue hypertrophied; the pigment in the rete and corium increased; 
the sweat-glands dilated; the lumen of the blood-vessels diminished, 

1 American Journal of the Medical Sciences, October, 1878. 

2 Lancet, February 28,1886, p. 380. 


HYPERTROPHIES. 


473 


and their walls ensheathed in accumulations of what he terms “ lym¬ 
phatic cells. ” 

The nature of the pathological process in scleroderma is unknown; 
no characteristic changes in the nervous centres have yet been appreci¬ 
ated. In the generalized form the two vascular systems, the sanguine 
and lymphatic, exhibit within and about the walls of vessels embry¬ 
onic cells which become converted into fibro-plastic bodies. This 
change produces in parts an increase in the thickness of the tunica 
media until it is twice the normal diameter. The lumen of the vessels 
is thus obstructed and at times obliterated, indicating that the essential 
process is an endarteritis obliterans, inducing, in the areas to which 
each twig of vessels is distributed, an exsanguinated state with a sur¬ 
rounding hyperemia. The latter accounts for the peripheral halo of 
the circumscribed forms of the malady. That there is at the same 
time lymphatic obstruction is clear, with, either from the one cause or 
the other, an overproduction of connective tissue and elastic fibres in 
the areas of involvement. The corium is commonly hypertrophied, 
at least in the papillary layer; while the subcutaneous tissue and pan- 
niculus adiposus are proportionately thinned; and even, at times, as 
suggested by the clinical features noted above, may wholly disappear. 
The pigment commonly vanishes from the prickle-layer; the coil- 
glands at first are dilated, and later may disappear when the atrophic 
stage is reached. In the late circumscribed forms the papillae of the 
corium may also fall into atrophy, and the superior vascular plexus of 
the corium undergo obliteration by thrombosis (Crocker). The com¬ 
pression of both glands and vessels is supposed to account for the final 
sclerotic and cicatriform condition of the advanced cases. 

Diagnosis. In vitiligo there is an entire absence of all structural 
cutaneous changes and the skin has the characteristic milky-white 
color, the hairs of the part being also blanched. Both the pig¬ 
mented macules and atrophic patches of lepra are remarkable for their 
anesthetic condition, and their coincidence with, or sequence from, 
other readily recognized symptoms of the disease, such as tubercles, 
bullae, ulcers, and involvement of the hairs, nails, eyes, and other 
organs. 

In sclerema and oedema neonatorum the age of the patient would in 
general serve to distinguish the disorders, as the subjects of these dis¬ 
eases commonly exhibit symptoms long before the conclusion of the 
first year after which scleroderma is first declared. In cancer en cuirasse 
(papillary cutaneous carcinoma), chiefly of the breast in women, but 
encountered elsewhere, the resemblance to scleroderma is in a high 
degree striking; and eminent surgeons have committed the error 
of confounding the two. In both affections the skin, especially 
that of the thorax, is converted into a dense leathery unimpressible 
cuirass, but the distinction is made as follows: first, the carcino¬ 
matous condition of the skin may be secondary to a cancerous change 
in the breast or nipple, in which case the doubt is readily removed; 
second, if primary, the firm, isolated, and deeply tinted nodules of 
cancer are readily distinguished, projecting from the dense peripheral 
cutaneous infiltration; third, the oedema and lymphangitis associated 


474 


DISEASES OF THE SKIN. 


with cancerous involvement are most often unilateral, and are limited 
very distinctly to an arm on one side of the body corresponding with 
the side most seriously involved; fourth, the line of demarcation of 
the cancerous change, while indeterminate on one side, is usually at 
the edge of advance distinguishable by tongue-like erythematous pro¬ 
longations of a dull-reddish hue; lastly, the tendency to ulceration, 
the coincident and resulting cachexia, the possible axillary adenopathy, 
and the relatively rapid and fatal result in cases at all liable to be con¬ 
fused with scleroderma, point severally to the truth. 

In ichthyosis the congenital history, the presence of ichthyotic 
plates over the affected surface, and the general conservation of the 
health of the patient would suffice to identify the disease. 

In progressive lenticular melanoderma (angioma pigmentosum et 
atrophicum) the melanotic condition of the skin, in connection with 
warts, tumors, ulcers, and limitations of the disease to the exposed 
parts, suffice to distinguish its character. 

Treatment. The most important consideration in the management 
of scleroderma, when either symmetrical or with a disposition to gen¬ 
eralization, relates to climatic effects. Certainly more improvement 
is secured for these patients after their removal to a dry and equable 
climate than can be obtained elsewhere. If they must remain under 
unfavorable climatic influences, the body should be well protected by 
woollen, over muslin, silk, lisle-thread, or balbriggan undergarments; 
and while an outdoor life is desirable, such exposure should always be 
avoided in unfavorable weather. Internally, cod-liver oil, the ferru¬ 
ginous tonics, and the nutrients generally are often indicated, as well 
as a roborant and generous diet. The employment of the iodid of 
potassium, arsenic, mercury, and other remedies, such as benzoate of 
lithium, sodic bicarbonate and salicylate, and the alkalies, supposed to 
be indicated by the rheumatoid symptoms, have been both praised 
and condemned by men of eminence on both sides of the Atlantic. 
Remedies of the reconstituent order should always first be employed, 
and no resort be had to others save in emergency. 

The local treatment is by baths, massage, galvanism, alternate hot 
and cold douches of the spinal column, inunctions with cod-liver oil 
and medicated salves, and the actual cautery over the spinal cord. 

The simpler is without question the better method where authorities 
differ. It is, therefore, better for most cases to employ inunctions 
with lanolin, lard, or vaselin, or combinations of these with a small 
quantity of neat’s-foot oil, slightly scented, after the daily salt-and- 
water or alkaline bath of a temperature to be suited to the season of 
the year and the physical condition of the patient; and to render 
these articles more stimulating or combine with them a special medica¬ 
ment only when improvement is not marked. 

Prognosis. Symmetrical diffuse scleroderma, well treated in young 
subjects, results favorably without impairment of the general health 
for most of the cases. When atrophic changes occur, the skin may 
recover its suppleness and pliability, but this cannot be counted upon. 
Deformity may in either event complicate an otherwise favorable issue. 


HYPERTR OP HIES. 


475 


In some, probably not more than one-third to one-fifth of all eases, 
cachexia or intercurrent disease closes the history. 

In circumscribed patches (morphea) the majority recover without 
serious consequences; the few go on to sclerosis of subcutaneous struc¬ 
tures and consequent deformity. For the most of the cases of the last 
order the disease from first to last seems to have but a local significance. 


MORVAN’S DISEASE. 

(Syringomyelia, Analgesic Paralysis with Whitlow. 

Fr ., Panaris Analgesique.) 

Morvan’s disease is a paretic affection chiefly involving the upper 
extremities, accompanied by pain, and producing a series of whitlows, 
affecting first one side of the body and then the other. 

Symptoms . In this disorder the arm is commonly first involved, the 
approach of the disease being insidious and usually first noticed on 
account of the production of pain and some loss of nervous and mus¬ 
cular power. At times the first signs of involvement are the produc¬ 
tion of whitlows, which either early or late are tolerably sure to appear 
in every case. In other instances the disease first displays an anal¬ 
gesia similar to that occurring in some subjects of lepra, the attempt 
having been made to establish a relation between the two diseases. In 
time atrophy of the interosseous muscles, of the flexors of the wrist, 
and of those forming the thenar and hypothenar eminences may result. 
The integument of the affected limb has a bluish or empurpled look; 
it may be thinned or thickened, and the seat of fissures, vesicles, and 
bullae, as well as of the characteristic whitlows, which vary in number 
from two to four or six. Ulceration extending as deeply as to the 
tendinous sheaths may result, and, as a consequence of one or more 
of the changes described above, the phalanges may necrose and be 
separated as a whole. 

A series of trophic disturbances arise in connection with the disease, 
pointing for the most part to au origin in disturbances of the centric 
nervous system. Among these disturbances may be named: hyperi- 
drosis; diminution of, variability in, or complete absence of the reflexes; 
visual changes; contracture of the fingers; and a general distortion of 
the hand. Scoliosis and arthritic complications have been recorded in 
a number of cases. 

The disease is usually protracted in its course, lasting in some cases 
for a quarter of a century. 

Etiology. The affection may first develop in childhood and last till 
middle life and longer, though more often it is first noticed after the 
occurrence of puberty. Women are much less often affected than men. 
Traumatism, malaria, and rheumatism have all been cited as possible 
causes of the disease. Its exact etiology is obscure. 

Pathology. The changes which have been discovered in the nerves 
distributed to the affected parts have been: neuritis, thickening of the 
neurilemma, and sclerosis of the posterior cornua and columns of the 


476 


DISEASES OF THE SKIN. 


cord. The cavities recognized in the central canal, distended with fluid, 
are supposed to be due to absorption of gliomata. 

Diagnosis. The recognition of a fully developed case of Morvan’s 
disease is readily established by taking into consideration the paretic 
symptoms present, the whitlows, and the disturbances in sensation, 
more particularly in appreciation of temperature-changes, pain, and 
contact with foreign bodies. Attention has already been directed to the 
striking resemblance between certain phenomena of anesthetic lepra and 
those of both syringomyelia and Morvan’s disease. With respect to the 
diagnostic difference between the two last-named affections, it is claimed 
that in most cases of syringomyelia the sense of touch remains unim¬ 
paired. The time, however, is probably not distant when the two 
will be recognized as slightly differing manifestations of the same mor¬ 
bid state. Scleroderma and glossy fingers are to be differentiated by 
the special peculiarities of each. 

Treatment is to be conducted on the general principles, surgical and 
medical, relied upon for meeting the indications of each case. In 
general the hygienic and dietetic management of the patient with a 
highly roborant regimen is conducive to recovery. Many of the 
affected subjects of the disease have been reported as relieved or even 
wholly cured. 


ELEPHANTIASIS. 

(Gr. etecpag, elephant.) 


(Elephantiasis Arabum, Pachydermia, Bucnemia Tropica, 
Elephant Leg, Barbadoes Leg.) 


Statistical frequency in America, 0.046. 

Elephantiasis is a chronic disease of the cutaneous and subcutaneous tissues, usually 
limited to certain regions of the body, preceded by the occurrence of some inflam¬ 
matory process in the blood- and lymphatic-vessels of the affected part, and 
resulting in an enormous increase in its volume, with hypertrophy of the struc¬ 
tures of which it is composed. 

Under this title has been included a group of affections differing 
both as to their essential cause and nature. On the one hand, are to 
be recognized those disorders due to obstructive embarrassment, simple 
or even mechanical in character, of either the venous or the lymphatic 
circulation; and, on the other hand, obstructive embarrassment due to 
the presence in the vessels of a parasite, the jilaria sanguinis hominis. 
The symptoms of the two disorders are for the present considered 
together. 

Symptoms. The disease is more common in the tropics, where it is 
usually of parasitic origin; but sporadic cases are of occurrence in all 
countries and not very rare in portions of the United States. The most 
frequent seat of elephantiasis is the lower extremity of one side, where 
the foot and leg (Fig. 57), though also the thigh of the same limb, may 
enlarge. The penis and scrotum of men (Fig. 58), the labia and clitoris 


HYPER TR OPHIES. 


477 


of women, the upper extremities, the face, and portions of the trunk 
may likewise become involved. 

The disease is insidious in its approach, and remarkably chronic in 
its career. Usually, localized inflammations precede, as an erysipelas 
or a dermatitis, with or without some involvement of the lymphatic 
vessels and glands. At the same time there is a condition of general 
fever, to which succeeds a defervescence, with abatement of the local 
inflammation, its sequels becoming manifested in a more or less per¬ 
sistent oedema of the part lately inflamed. After intervals of days, 
weeks, or months, the pyrexia recurs with still greater involvement of 
the swollen tissues, which, with each access of fever, increase in volume 
and gain in density. When the elephantiasic condition is fully devel¬ 
oped the skin is found to be tense, glossy, and blanched or discolored 
in various shades. Pressure upon the oedematous part is followed by 
pitting, but the tissue beneath is felt to be brawny and indurated. The 

fig. 57 . 



Elephantiasis of the foot and leg. 


parts beneath the skin are perceptibly increased iu volume, especially 
the subcutaneous tissue; and the circumference of a limb thus diseased 
may be several times larger than that of its fellow. A lymphangitis 
is usually declared by painful, cord-like, linear indurations of the part, 
associated with adenopathy of the nearest ganglia. In older cases the 
skin loses its glabrous aspect, and exhibits eczematous, verrucous, papil¬ 
lomatous, seborrheic, and even ichthyotic changes. Pigmeutation, even 
to a blackish tint, may ensue; scaling, Assuring, and furrowing are 
common; and the accumulation of altered sweat and sebum in these 
depressions is the source of an offensive stench. During the course 
of the disease almost all the elementary lesions of the skin may be dis¬ 
played by the skin, macules, vesicles, papules, tubercles, pustules, blebs, 
ulcers, crusts, scales, excoriations, and fissures. Warty growths form 
as large as those seen in ichthyosis hystrix, and in some cases reddish- 
colored tumors spring from the hypertrophied integument. 

When fully developed in the lower extremity the unwieldy limb, 
with the foot, ankle, and leg massed into one huge, cumbrous cylinder 


478 


DISEASES OF THE SKIN. 


(Figs. 57 and 58), bears a striking resemblance to that of the elephant, 
from which circumstance the malady first received its name among the 
Arabs. Locomotion is then greatly impeded or is rendered impossi¬ 
ble. No less striking is the similar deformity of the genital labia of 
women or the scrotum of the male, the latter at times hanging far 
below the knees (Fig. 58). 


Fig. 58. 



Elephantiasis scroti. 


In its rugons folds the penis disappears, and the urine is passed 
along a gutter formed of skin transformed into quasi-mucous membrane. 
As a consequence of the fissures and excoriations which form, the lym¬ 
phatic channels are finally opened, and a true lymphorrhea results. 
After similar process the ear may become largely pendulous by the 
side of the neck. 

Subjectively, the disease may be regarded as productive of less dis¬ 
comfort than would be suggested by its formidable features. Pain is 
occasionally experienced, and, during the exacerbations accompanied 
by pyrexia, there is corresponding malaise. The chief subjective sen¬ 
sations are those induced by weight and consequent tension, inseparable 
from the enormous masses of hypertrophied tissue. 

In elephantiasis of the scrotum there are frequently symptoms of 
irritation, both systemic and in the vicinity of the affected part (nausea, 
vomiting, inguinal pain, epididymitis, effusion into the sac of the tunica 
vaginalis, inflammatory swelling of the spermatic cord, and at times 
hernia). In some cases vascularization of the surface (telangiectatic 
elephantiasis) is a prominent feature. The form described below as 
Nevoid Elephantiasis may belong either to the same category, or to 
others in which there is lymphangiectasis (“ lymph-tumors / 9 “ lymph- 
scrotum”), and these may either be due to lymphatic obstruction or 


PLATE VI. 



Elephantiasis Telangiectodes of the Upper Lip and Portions of the Face. 


[From a photograph ot one of the author’s patients.] 














HYPER TR OPHIES. 


479 


to the parasite described later as of etiological importance in this con¬ 
nection. 


Lymph-scrotum (Varix Lymphaticus, Nevoid Elephantiasis), 
fully described by Wong, Carter, Fayrer, Manson, 1 and other East 
Indian observers, is that condition in which the inguinal and femoral 
glands become large and soft, and the scrotum is covered with vesicles 
and distended with dilated lymphatic vessels all filled with coagulated 
lymph. As in elephantiasis of other organs, there may be preceding 
fever, chills, erysipelas, and other localized inflammations. The dis¬ 
ease is produced solely by the filaria sanguinis hominis, and it may be 
associated often with chyluria in one instance, and elephantiasis of 
other organs in another. 2 

Cases originally reported of hypertrophy of one-half the face, are 
also to be assigned to the group of maladies to which the name elephan¬ 
tiasis is applied, excluding the parasitic and lymphangiectatic varieties. 
KiwalPs patient, a girl eighteen years old, with an enlargement extend¬ 
ing from brow to throat and involving the right side of the tongue as 
well as the bones and other soft parts, is an example of this anomaly. 
Crocker, Hebra and Kaposi, Barwell, and others report similar 
instances. One such, the subject of a skilful operation by Professor 
Senn, suffered from a marked enlargement of one side of the face, due 
in part to an angiomatous and in part to a connective-tissue overgrowth. 

Acromegaly. Cases of this rare form of elephantiasis are not 
infrequently reported. A typical instance of the malady has been 
made the subject of an interesting monograph (with illustrations of 
the facial and manual deformity) by Dr. Archibald Church, and 
by Dr. William Hessert. 3 The disorder is also well illustrated by 
Waldo, 4 who describes a cachectic-looking male patient, aged fifty-four 
years, with enlarged hands, fingers, and knee as well as other joints, 
which organs, as a result, were so clumsy as to prevent the manage¬ 
ment of his person. The hands looked like paws; the fingers were 
enlarged in all proportions, their joints apparently not more involved 
than other parts. The ilia, zygoma, and arches of the orbit were also 
thickened. There were coincident symptoms of bulbar paralysis with 
convulsions and a fatal result. Post mortem cavities were found in 
the brain and kidneys, calcareous changes in the tissue of the cardiac 
valves, and caseating masses in the lungs. 

Etiology. The causes of elephantiasis are different in the several 
disorders grouped together under this title. Wucherer, Lewis, and 
Manson have demonstrated in cases prevalent in the East and West 
Indies, Egypt, Arabia, Abyssinia, Africa, Malabar, Barbadoes, Brazil, 
Mexico, and parts of China, the presence in the blood of the filaria 
sanguinis hominis. Embryos and filaria are found adhering to the 


1 TTircoh • TTnndhnnlr of Gene' and Hist. Path., London, 1885, p. 328. 

2 At the third International Congress of Dermatology, held in London in 1896, Manson exhibited 
living specimens of filaria moving in the bloodvessels under the microscope. 

3 Medical Record, May 6,1893 (reprint). 4 British Medical Journal, March 22,1890. 


480 


DISEASES OF THE SKIN. 


walls of both lymphatic vessels and blood-vessels in elephantiasis of 
the tropics. 

Manson, who investigated the subject carefully and extensively, says 
that in countries where elephantiasis is common the majority of the 
healthy natives have filaria in their blood. The parent worm lives 
in a large lymph-channel and produces young in immense numbers 
which circulate in the blood. It is only when the parent worm aborts 
and the immature filaria are unable to pass through the lympatic glands 
that the circulation is obstructed. Thus it often happens that filaria 
are no longer found in the blood of an individual who has developed 
elephantiasis. 

Other disturbances due to the same parasite and only in part recog¬ 
nized as elephantiasic, are the lymph-scrotum described above, chylous 
abscess, effusions, and vascular and hypertrophic enlargement of tissue 
and glands in and about tumors of the sort recognized as parasitic. 

In other cases different causes are to be recognized. Predisposition 
of races or individuals, heredity, climatic influences, malaria, fatiguing 
labor with the feet and legs immersed in water, and filth in connection 
with u misery,” have all been cited as favoring conditions. To these 
causes should be added the local disorders especially common in the 
lower extremities that have in cases proved to be points of departure 
of the elephantiasic hypertrophy, such as obstruction to the blood- or 
lymphatic currents by pressure of tumors, pregnancy, or neoplasms; 
ulcers, cicatrices, and traumatisms by pressure or friction; cutaneous 
diseases; systemic affections (syphilis, tuberculosis); and osseous disease. 

Pathology. Even macroscopically the elephantiasic mass is seen to 
be built up of hypertrophic elements representing all the tissues of 
which the part is composed. The knife with difficulty divides the homo¬ 
geneous, whitish, and lardaceous mass, from which on pressure exudes 
a fluid of similar color. The subcutaneous connective tissue is found 
relatively much more enlarged and sclerosed than the epidermis and 
derma; though when section is made through the rugous and warty 
skin described above all the elements of the papillary layer, rete, and 
stratum corneum are seen to participate in the changes described in 
connection with the pathology of verruca. Here and there are loculi 
filled with a fluid lymph. The sheaths of the blood-vessels, lym¬ 
phatics, nerves, and the bones, muscles, and aponeuroses are also 
thickened, solidified, and occasionally agglutinated, so as to be almost 
indistinguishable in the mass of uniformly sclerosed tissue. The pig¬ 
mentation of the derma is marked, the nuclei of the connective-tissue 
cells are multiplied, and the cutaneous glands intact, hypertrophied in 
their epithelial linings and investments, or, at a later stage, atrophied. 

It is evident that in many cases, as Virchow has pointed out, the 
earliest of the changes to be noted occur in the lymphatic glands and 
vessels, the whitish and yellowish lymphatic fluid which then accumu¬ 
lates in the tissue resulting from obstruction of the lymph-channels. 
In some of the remarkable cases on record the lymphatic obstruction 
is the prominent feature of the disease, and the elephantiasic enlarge¬ 
ment is subordinate in gravity to the former condition. Such are, for 
example, the noteworthy instances in which the lymph distends mul- 


HYPER TR 0PH1ES. 


481 


tiple cutaneous vesicles, after rupture of one or more of which the 
fluid streams away to a dangerous extent. For a fuller description of 
this interesting class of cases the reader is referred to Busey’s careful 
monographs on Occlusion and Dilatation of the Lymph-channels. 

Diagnosis. The striking deformity which characterizes elephantiasis 
will always suffice for its recognition. In the earliest stages of the 
disease, when merely an erysipelatous or an eczematous condition of 
the skin can be determined, it would be difficult, if not impossible, to 
decide as to the future of the disorder, especially in a locality where 
only sporadic cases occur. A symmetrical hypertrophy of both legs 
and both feet, developing in America, even though described as “ ele¬ 
phantiasis/ ? should most carefully be studied before a diagnosis is 
made of the particular disease here considered. The same might even 
be said of elephantiasis of but one inferior extremity. A patient with 
an extensive deforming induration and enlargement of the right 
leg and foot, accompanied by pigmentation and a well-marked warty 
condition of the skin, who had been pronounced the victim of idio¬ 
pathic elephantiasis arabum, had received a fracture of the upper 
third of both bones of the same leg during the previous year, and had 
since the accident constantly worn a tight bandage encircling the limb 
at the seat of the injury. The deformity rapidly disappeared under 
the application of a roller bandage extending from the toes upward. 

A peculiar and rare, though characteristic, deformity of the labia 
majora of women—most commonly the labium majus of one side— 
results from a tertiary syphilitic, gummatous infiltration which must 
be distinguished from elephantiasis. In cases of this kind the history 
of the patient and the relative inferiority as to bulk of the affected 
organ point to the nature of the disease. The syphilitic labium rarely 
exceeds the size of that of a large fist. 

A gigantic hypertrophied mass of elephantiasic type is occasionally 
to be discovered in the lower extremity of one side only in women who 
have been for many years the victims of an unrecognized and long- 
untreated syphilis. Even when the leg is many times its normal size 
and weight and its contour lost in thickened and roughened epidermis 
resembling the bark of a tree, the diagnosis may be made by dis¬ 
covering, here and there in the depth of the mass, circular and charac¬ 
teristic scars of healed gummatous ulcers. 

Treatment. In the early stage of elephantiasis the febrile condition 
of the patient and the localized cutaneous inflammation are to be 
treated by the measures appropriate for the relief of these conditions. 
Quinin, especially in malarial districts, is of the highest importance. 
Wheu the elephantiasic development is established, if the genitals are 
involved, the knife of the surgeon offers the best prospects. The result 
of such interference, both in the genitalia and the extremities, has in 
many cases been brilliant indeed, though the mortality of such severe 
operations is necessarily great. When the lower extremity is involved, 
it should be maintained in a horizontal position, its ulcers if possible 
be healed, its excrescences removed, its circumscribed inflammations 
resolved, and then elastic compression be carefully and skilfully main¬ 
tained by means of the rubber bandage. The toes are first separately 

31 


482 


DISEASES OF THE SKIN. 


enveloped, then the foot and ankle, and lastly the leg. The results are 
sometimes highly satisfactory. 

Ligation and digital compression of the main artery supplying the 
elephantiasic leg have occasionally been followed by transient improve¬ 
ment. Instrumental compression has at times resulted in severe ulcer¬ 
ation and a reawakening of the erysipelatous affection. Multiple 
punctures and incisions, made with a view to giving exit to the fluids 
contained in the mass, have been attended by no greater success. The 
main obstacle in all these surgical procedures is the lymphangitis which 
so frequently complicates the situation. None of them promises so 
well as nerve-stretching, which, in a few isolated cases, has been fol¬ 
lowed by noteworthy results. Excision of a portion of the sciatic 
nerve has also been followed by satisfactory changes. The use of the 
galvanic current has, when long continued, accomplished resolution of 
engorged masses of tissue. Elastic compression in the horizontal posi¬ 
tion for all cases not warranting nerve-stretching, may be regarded as 
the wisest course when the extremity is involved. For the local treat¬ 
ment of the pachydermia proper, green soap, mercurial ointment, aud 
bathing in hot or cold lotions, may advantageously be employed. For 
patients whose disease is acquired in countries where the deformity is 
prevalent, a change of climate is of the highest importance; and, hav¬ 
ing in view the social surroundings and habits of most victims of the 
disease, it is scarcely necessary to call attention to the need of a proper 
hygiene, diet, and tonic regimen. 

Prognosis. The future of a patient may be regarded as most favor¬ 
able when the disease exhibits an early tendency to respond favorably 
to appropriate treatment, and when circumstances permit of a resort to 
the best therapeutic measures which can be adopted, such as change of 
residence, persistent and careful dressing of the affected part, and the 
removal of any exciting cause of the disease, such as a neoplasm, an 
indurated cicatrix, etc. In the severer cases a fatal result may be pre¬ 
cipitated; but usually life is prolonged, burdened by the inconvenience 
of the enormous elephantiasic mass in comparison with which the rest 
of the body often seems to serve as a mere appendage. 


ROSACEA. 

(Lat. rosa, rose.) 

Rosacea is a chronic cutaneous disorder, chiefly of the face, characterized by irregu¬ 
larly disposed, rosy or reddish maculations, often produced by acquired telangiec¬ 
tasis of the skin capillaries, or forming split-pea-sized and larger hypertrophic 
nodules most commonly seated upon or about the nose. 

The condition of telangiectasis described under this title is almost 
identical as regards its clinical features with acne rosacea (Gutta Rosea, 
Copper-nose), to the chapter on which the reader is referred. In what 
follows, the attempt is made to portray the affections of this class which 
may properly be described as hypertrophic in character; relegating 
the acneiform cases to the chapter clevoted to Acne Rosacea. 


HYPER TR OPHIES. 


483 


[A] Erythematosa. 

Symptoms. The eruption is usually displayed in middle life or later, 
and chiefly upon the face of both sexes. The uose (tip, alee, root), 
brow (especially near the root of the nose), chin, cheeks, temples, or 
lips, may be the seat of reddish or rosy blotches. The effect is a 
marked unsightliness, for which chiefly, or only, the advice of the phy¬ 
sician is sought. These maculations are usually unproductive of sub¬ 
jective sensations or of objective feeling of heat. They may be so 
numerous as to implicate all the regions named above to a great degree, 
or be limited to one or two adjacent regions, or, lastly, be spread very 
profusely over the entire face in minute blemishes not more developed 
at one point than another. 

The very greatest irregularity may be noted as to their contour, the 
spots being pin-poiut- to nail-sized, roundish, radiating, stellate, linear, 
tortuous, or in any fantastic outline. The colors vary from a delicate 
rosy-pink to a deep-purplish crimson. Viewed with care, all are seen 
to be produced by a double process of dilatation and new formation of 
skin capillaries. 

This condition is subject to marked aggravation, or at least to tran¬ 
sient change of features, after the operation of any cause tending to 
congest the blood-vessels of the head, as stimulation by food or drink 
or both, coughing, laughing, sneezing, active exertion, the application 
of hot water to the surface, exposure to the sun, etc. After such 
occurrence the blood will visibly distend the vessels of the face, the 
color deepen and spread, and all features of the disorder become decid¬ 
edly conspicuous. Often a coexisting acne or seborrhea fluida faciei 
participates in these changes. The disease is seen with almost equal 
frequency in both sexes, but women rarely exhibit the succeeding stage 
of the disorder, next described. 


[B] Hypertrophica. 

After a longer or shorter persistence of the condition described above, 
a new formation of connective tissue with cell-infiltration proceeds pari 
passu with the telangiectasis. In this way small or large pin-head- to 
egg-sized tumors are developed, more particularly about the tip or the 
ahe of the nose, reddish or purplish in color, until the stage is reached 
which is elsewhere described as “ rhinophyina.” The absence of 
inflammation in these cases is marked. The nose is often cold to the 
touch when bright-red in hue, and it may be peculiarly oily or greasy 
in appearance in consequence of a seborrhea oleosa of the part. The 
so-called “ brandy-drinker’s,” “ wine-drinker* s,” and “whiskey- 
drinker’s” noses are of this class. 

Etiology. The disease in its milder manifestations is common to 
both sexes, the hypertrophic forms being rarer and practically limited 
to men. The causes of the disorder are numerous, but they always 
operate by producing at first active or passive distention of the blood- 


484 


DISEASES OF THE SKIN. 


vessels of the upper portion of the body. Among these effective 
causes may be named gastric dyspepsia (especially though not exclu¬ 
sively associated with intemperate use of alcoholic stimulants, includ¬ 
ing brandy, whiskey, wine, and beer); articles of clothing, surgical 
apparatus, tumors, etc., compressing the larger vessels at the root of 
the neck; the long-continued action of heat and cold upon the face, as 
also the local effect of chemicals ; and the influence of certain trades 
and occupations of life tending to produce congestion of the face, as, 
e.g ., among cooks, cab-drivers, swimming-teachers, etc. In some 
cases there is a distinctly inherited tendency to distention of the capil¬ 
laries of the skin of the face; in other cases the rosaceous blemish 
is congenital. Diseases of the uterus and other viscera may be remote 
sources of the trouble. 

Pathology. The hyperemia usually begins as a transitory phenom¬ 
enon in the more deeply seated plexus of vessels, and, after permanent 
distention has resulted, the vascular elements of the more superficial 
strata of the corium and those surrounding the sebaceous glands and 
hair-follicles become involved. In the hypertrophic lesions there are: 
new formation of connective tissue, enlargement of all portions of the 
corium, hyperemia and telangiectasis of the vessels, and dilatation of 
the sebaceous glands. 

Diagnosis. Acne rosacea is to be distinguished from uncomplicated 
rosacea by the characteristic lesions of the former, comedones, papules, 
pustules, crusts, etc. In uncomplicated rosacea there is only a macular 
lesion due to hyperemia or telangiectasis. The two disorders, thus 
artificially distinguished, are often found the one complicating the other, 
an acne being the origin of the hyperemia, which is the first rosaceous 
stage. The hypertrophic lesions of rosacea are also thus associated 
with acneiform symptoms. Lupus, carcinoma, and syphilis of the 
regions affected by rosacea, are commonly productive of ulcerative or 
destructive consequences which point to the nature of those affections. 

Treatment. The treatment of rosacea is practically the same as that 
of acne rosacea, to the chapter devoted to which the reader is referred. 
The vessels producing the rosaceous blemish are to be destroyed, pref¬ 
erably by electrolysis; but the result may also be accomplished less 
elegantly and perfectly by incisions, followed by cauterization; by 
curetting; by the Paquelin knife; by Brun’s sharp spoon; by Vidal’s 
lancet; or by fche multiple scarificator—the last-named instrument being 
only available for the larger lesions. The hypertrophic forms of rosa¬ 
cea are best remedied by the plastic operations of modern surgery. 

Prognosis. The lesions of rosacea, limited in extent, even though 
quite numerous, may elegantly and permanently be removed by electro¬ 
lytic methods. The scars left, after operations upon the larger lesions 
are usually superficial, and not disfiguring. The prognosis, after abla¬ 
tion of the largest hypertrophic lesions, is proportioned to the resources 
of surgery. In no case does general disease result. 


H YPER TR 0 PHIES. 


485 


FRAMBESIA. 

(Fr. framboise , raspberry.) 

(Yaws, Pian, Lepra Fungifera, Toboe, Polypapilloma Trop¬ 
ica, ScHWAMMFORMIGE, BuBA OR BOBA, BOUTON d’AmBOINE, 
Tonga, Coco, Framosi, Tetia, Lupani, Tono, Peruvian 
Wart, Parangi.) 


Frambesia is an infectious disorder existing as an endemic malady in certain tropical 
countries, and affecting for the most part individuals of the African race, and is 
characterized by the development, upon the skin, of papules and tubercles, covered 
with brownish-yellow crusts, on the removal of which the lesions present an 
appearance suggestive of the raspberry. 

Contributions to the literature of this subject have been made by 
Pison, Bontius, Hillary, Winterbottom, Schilling, Milroy, Nicholls, 
Imray, and Bowerbank. The description here given is largely bor¬ 
rowed from an elaborate paper 1 on the subject contributed by Dr. 
George Edmund Pierez, to the Pan-American Medical Congress held in 
Washington in 1893. 

There are two defined stages of the disease: one of incubation; 
another of invasion. In the first stage there may be moderate febrile 
symptoms; in the second stage there are usually malaise, articular pains, 
tenderness and fulness of the lymphatic ganglia, and an eruption con¬ 
sisting of tubercles which requires from two to nine days for complete 
evolution, the disease lasting from two to six months in mild cases, and 
in the severe forms for two years or more. The aggravating influ¬ 
ences following the longer periods of the disease are: lack of suitable 
hygienic surroundings, improper medicinal treatment (e. g., the admin¬ 
istration of mercury under the supposition that the disease is syphilitic), 
and the dyscrasias in general. The eruptive phenomena are described 
under several heads: 

(а) Pian dartre (“ yaws caeca ”), in which there occurs on the face 
and extremities a furfuraceous desquamation which is usually well- 
defined and limited to patches ranging in size from that of a coin to that 
of a pea. In cases this desquamation may extend over the entire sur¬ 
face of the body. In some instances, when the scales are removed, 
papillary projections are visible beneath. 

(б) The yaws tubercle. The tubercle of frambesia varies in size 
from that of a millet-seed to that of a coin, covered at first with a 
thinned epidermis and later forming an excrescence of verrucous type 
with numerous aggregated pinkish points which furnish a secretion, 
desiccating later into a greenish-yellow, bulky crust, shaped like the 
shell of the limpet and resembling in color and consistency lumps of 
yellow beeswax. Reddish puncta, due to small hemorrhages, may here 
and there be visible at the surface. Crusts are less apt to form in 
regions near the mucous outlets of the body (vulva, anus), and at 

1 Transactions of the First Pan-American Medical Congress, Washington. Government Printing 
Office, 1895. Part II. p. 1764. 


486 


DISEASES OF THE SKIN. 


points subjected to friction (axillae, groins). There may be a delicate 
halo about each crust. The odor is mawkish. A- degree of sym¬ 
metry may be perceptible. By confluence a few unusually large excres¬ 
cences may form (“ mama pian ”). While the larger are thus coales¬ 
cing and enlarging, other smaller tubercles may shrivel and disappear. 

(c) Pian gratelle (“ guinea-corn yaws”), which is the rarest form of 
all, is characterized by the development of watery-looking, light pur- 
plish-hued tubercles, destitute of crusts. 

(d) Crab-yaws ( “crapeaux ”). In these cases fissures occur in the 
tubercles which are usually located on the soles of the feet and are 
aggravated by the exposure of these organs when walking barefooted. 

(e) Ringworm yaws. The eruption may occur in circular ridges 
surrounding an unaffected centre, the original lesions of this enclosed 
area having undergone a species of shrivelling. When this process is 
completed by the fall of the crusts, no scars are left, the epidermis 
being pigmented as after the involution of syphilitic tubercles. 

Under unfavorable conditions ulceration of the tubercles occurs, 
leaving raw patches (often on the anterior faces of the legs) ranging in 
size from that of a small coin to areas having a diameter of several 
inches. Their edges are punched-out in appearance; the floors are 
granular and bright reddish in hue. 

Diagnosis. The distinction between frambesia and psoriasis and 
eczema is readily effected by consideration of the distinctive peculiari¬ 
ties of the several disorders named. It is chiefly the distinction from 
syphilis that has engendered confusion in the past. The following are 
important points of distinction: syphilis often, yaws rarely, attacks 
the mucous surfaces, the last-named disease much more rarely involv¬ 
ing the lymphatic glands; there is usually itching in the yaws eruption; 
there is no characteristic copper color in its eruptive features; yaws does 
not affect the bones save in the continuity of long-standing ulceration of 
the skin; the subject of yaws is susceptible to indefinite auto-inocula- 
tion; yaws though common in children is not inherited, healthy parents 
may have infants seriously affected with frambesia; lastly, the two 
diseases have been noted as of concurrence in the same person. 

Etiology. The disease chiefly occurs in the black races, and especially 
among the filthy, though it is seen also among the whites. 

Pathology and Bacteriology. The disease is caused by a specific microbe 
—a rod-shaped bacillus—occurring singly and also in couplets and 
triplets, and being about 2 g in length and 0.5 g in breadth. It is 
readily cultivated in nutrient jelly, and is capable of transference, with 
production of yaws not only upon the skin of man, but also upon the 
surface of the lower animals, especially that of the cat. 

Treatment.- The disease yields readily in the simpler cases to mild 
parasiticides; in severe cases tonics are required internally, such as 
iron, quinin, and strychnin. 

The prognosis is favorable save in broken-down subjects. 




HYPER TR OPHIES. 


487 


Parangi. 

Kynsey presented a report upon the nature of this disease which is 
thus designated in Ceylon, where it prevails. 

It appears to present mixed features of syphilis, land-scurvy, yaws, 
pellagra, lupus, leprosy, scrofula, and less severe disorders, existing as 
an endemic in certain provinces of the island. It is clear, from the 
description of the symptoms recorded, that the nature of the disease 
has not yet been recognized. It was first described in 1868 by Loos, 
and is now regarded as due to numerous causes, such as malnutrition 
induced by impure food and water, wretched hygienic surroundings, 
and infection from the discharges from ulcers. 

# There is, according to Christie, 1 an incubation-period of from two to 
eight weeks, followed by the appearance of an ulcer over any bony 
prominence—the initial sore. This period is succeeded by malaise and 
pyrexia, the premonitory fever lasting from two to eight days, and is 
followed by the exanthem, which appears first over the face, and later 
upon the body. This eruption may be vesicular, pustular, pustulo- 
tubercular, or squamous, superficial ulcerations forming which become 
crusted subsequently. Rupioid, furuncular, aud psoriasiform features 
are common in the course of the malady. Condylomata may appear 
at the anus. Ulcerations succeed later of a more formidable character, 
involving the nose, palate, and cheeks; the digits may be lost by gan¬ 
grene; blebs occur; pricking-pains are experienced; there may be 
anesthesia of some part of the surface, associated with bronzing and 
glazing of the skin. The patient may perish of some intercurrent dis¬ 
order or from exhaustion. The duration of the disease is said to be 
from two to eight years. 

Treatment has been successful with the cautious employment of mer¬ 
cury and the iodid of potassium, and strict observance of the rules of 
hygiene. 

Donda Ndugu. 

Donda ndugu (“ Brother ulcer/’ or “ Ulcer that clings”) is a disease 
existing in Central and Eastern Africa. Christie, 2 who first described 
it, believes it to be identical with that from which Livingstone suffered 
in 1870. 

The disease is confined to the lower extremities, and it occurs among 
the natives chiefly in the rainy season after a march toward the coast. 

It is characterized by the appearance of whitish papules springing 
from a boggy swelling, seen often near the toes, heel, or dorsum of the 
foot. When incised, an extensive, deep-seated slough is found beneath 
the healthy tissue, bathed in an ichorous discharge. Severe rapid¬ 
spreading ulcerations and death may ensue. Livingstone extracted 
the ova of a species of maggot from such lesions in his own person; 
but Christie failed to discover them in his cases. 

The treatment is local, by the use of antiseptics after incision. 


1 See Anderson’s Treatise on Diseases of the Skin. 


2 Ibid. 


488 


DISEASES OF THE SKIN . 


Verruga Peruana (Peruvian Wart). 

This is a specific disease, both endemic and at times epidemic, occur¬ 
ring for the most part in the mountains of Peru, and communicable 
by inoculation. There is a prodromic febrile stage, followed by the 
appearance on the skin of maculo-tubercular, softish, tender, and hemi¬ 
spherical tumors, which may attain the dimensions of that of a small 
or a large nut. Hemorrhagic effusions occur as a result of fissures in 
the epidermis covering the lesions, at times incoercible and leading to 
fatal anemia in severe cases. The lesions may be few or numerous; 
may occur on the several parts of the head and extremities (rarely on 
the trunk), and may eventually be desiccated or break down into ulcer¬ 
ations. A fatal result may occur at any stage from hemorrhage, or the 
disease may be relieved in the course of a few months. It is said to 
attack the whites more often and with greater severity than the negroes. 

Hirsch 1 and others have described the disease, an excellent outline 
of which is given by Crocker, who states that the mortality is from 6 
to 10 per cent, among the natives; and from 12 to 16 per cent, among 
the whites, or, in epidemics, 40 per cent. Bacilli have been recognized 
and may be the cause of the disorder. 


CLASS V. 

ATROPHIES. 

1. ATROPHIES OF PIGMENT. 

Absence of the pigment of the skin and hairs, giving rise to conspicu¬ 
ous disfigurement, is naturally most frequently encountered in those 
races of mankind whose skins are most abundantly provided with such 
pigment. The absence of pigment may be congenital or acquired, and 
be partial or universal. Some confusion has been produced by the 
arbitrary distinction established by authors between the names intended 
to designate these several varieties of achromatia or leucopathia. In 
the following pages leucoderma is the name employed to designate the 
pigment atrophy which is partial and congenital; albinismus, that 
which is universal and congenital; vitiligo, that which is acquired. 


1 Handbook of Geog. and Hist. Pathology, vol. ii. p. 114. 




ATROPHIES. 


489 


[A] Leucoderma. 

(Gr. tevicdc, white; dip/m, skin.) 

(Achromia, Leucasmus, Partial Albinism.) 

Statistical frequency in America, 0 062. 

Leucoderma is a partial congenital absence of pigment in the skin, most commonly 
observed in the colored races, and characterized by whitish patches or bands hav¬ 
ing an irregular border, the evidences of disease in such parts being limited to 
the changes in hue of the skin and the hairs 

Symptoms. In these cases, the patients being most often of the col¬ 
ored races, one or several whitish or rosy-whitish patches or bands, 
varying in size, outline, or situation, may be seen at birth unprovided 
with pigment. These patches may have a symmetrical arrangement, 
in which case they commonly observe the areas of distribution of one 
or more cerebral or spinal nerves, or they are asymmetrical in distri¬ 
bution. They are usually of circular outline, and may be found upon 
the scalp, face, nipple, breast, and genital region. The hairs found 
upon such parts are equally destitute of normal color, being usually 
white. Negroes thus marked are generally termed “piebald,” and 
the integument similarly affected in persons of other races has long 
been recognized as the Ci pied” or “ piebald skin.” These blemishes 
when symmetrical, like pigmentary naevi, exhibit a striking analogy 
with the symmetrical arrangement of the spots, bands, and stripes to 
be recognized in the furs of many of the lower animals. The outlines 
of the patch may be abrupt, or it may gradually shade into that of the 
adjacent integument. At times islands of pigmented skin are visible 
within the non-pigmented areas. The changes in these patches during 
later life may be insignificant, or they may individually increase in 
size with age, or even multiply. Rarely they regain pigment in later 
life. In no case is there an excess of pigment deposited at the border 
of the patch. 

This condition is practically remediless. 


[B] Albinismus. 

(Lat. albus , white.) 

(Complete Congenital Leucoderma.) 


Statistical frequency in America, 0.008. 

Albinismus is a congenital cutaneous achromia, characterized by universal defect of 
pigment, unaccompanied by textural changes in the skin. 

Symptoms. The term albinismus is here limited to the congenital 
conditions of achromia induced by universal failure of cutaneous pig - 

This deformity is peculiar to individuals known as “ albinoes 
(Kakerlaken; Dondos), isolated instances of this anomaly occurring 


490 


DISEASES OF THE SKIN. 


in all races, but more frequently among those having normally a hyper¬ 
pigmentation of the skin, such as negroes. In the subjects of this 
anomaly the skin has a milky-whitish, transparent, or rosy-tinted hue, 
and is usually of delicate texture; the hairs are silky and yellowish, 
whitish, or snowy-white in color; the iris, transparent or pinkish; and 
the pupil, in consequence of defect of pigment in the choroid, is also 
reddish or pinkish. There is, as a result, nyctalopia and heliophobia 
with frequent nictitation, pupillary variations, and the semblance of 
myopia. 

The pinkish hue of the skin in these individuals is due only to this 
translucency and vascularity. In no other respect, save as to pigment 
anomaly, does the skin of the healthy albino indicate disease; but the 
majority of persons thus deformed are far from vigorous. 

In albinism us the defective condition of the pigment is usually un¬ 
changed throughout life. It has been observed that some albinoes are 
physically inferior to the average of persons of the same sex, both in 
stature, weight, mental activities, and powers of resistance to disease. 
There are, however, numerous striking illustrations of the reverse of 
this, and the author has had under observation a number of albinoes 
in one family where alternations of non-pigmented with normally pig¬ 
mented children exhibited no difference whatever in sturdiness and 
vigor. Many of the enfeebled albinoes are simply illustrations of the 
wretchedly unwholesome life of persons imported for exhibition into 
foreign countries. 

Etiology. Inheritance is a frequent cause of this and similar pig¬ 
ment anomalies. The author has observed several members of one 
family affected with albinism and many such are on record. Alterna¬ 
tions in birth of white and black children in one family have been 
recorded also by other observers. 

The condition is remediless; though it is probable that transfusion 
with the blood of a vigorous black-skinued African would largely 
modify the color-characteristics of the pure albino. 


[C] Vitiligo. 

(Lat. vitium, a blemish.) 

(Acquired Leucoderma.) 

Statistical frequency in America, 0.155 

Vitiligo is an acquired cutaneous achromia, exhibited in single or multiple, vari¬ 
ously shaped and sized patches, unaccompanied by textural change in the skin, and 
usually bordered by tissues exhibiting pigmentary excess. 

Symptoms. The disorder is one observed among the several races, 
often in the negro, and not rarely among those of Aryan descent. It 
commonly occurs without the slightest appreciable disorder, subjective 
or objective, save that betrayed to the eye in the color-changes of the skin. 
One or several roundish, or very irregularly shaped, smooth, and well- 
defined, pale or milky-white lines, streaks, or disks appear, often 


ATROPHIES. 


491 



bordered at the periphery by an integument which assumes a light- or 
dark-brown or chocolate shade, this hue being by contrast most notice¬ 
able immediately at the contour of the patch, and imperceptibly fading 
into the normal color of the outlying integument. The hairs or 
lanugo-filaments growing from the affected area may or may not be 
blanched; most commonly they are, a condi¬ 
tion particularly conspicuous when, as is not 
rarely observed, a vitiliginous disk extends 
from the back or the side of the neck well into 
the scalp, in which case the outline of that 
portion of the scalp involved is clearly defined 
by the whitened pilary growth. 

Lesser describes a condition termed by him 
“ Poliosis Circumscripta Acquisita,” in which 
the hairs were thus blanched in a single area 
of an unaffected scalp, an observation which is 
confirmed in many cases. 

The surfaces thus blanched are otherwise 
unchanged. In point of subjective and objec¬ 
tive sensations, secretion from the follicles, 
and the condition of both epidermis and corium, 
there is, aside from the dyschromia, no depar¬ 
ture from a normal standard. The disease 
may progress by the coalescence of relatively 
small affected areas until a large portion of 
the trunk, the thighs, or the buttocks is in¬ 
volved. 

Hall 1 reports the case of a dark mulatto 
who became “ perfectly white,” with the ex¬ 
ception of a patch on the chin. Levy 2 reports 
three instances of total disappearance of pig¬ 
ment, It is then, as Kaposi has well shown, 
that the eye of the observer is struck no longer by 
the unusual whiteness of the involved patches, 
but, this whiteness being generalized and ap¬ 
parently that proper to the person, by the 
intermediate peripheral belts of a deeper and 
unusual color. The greater portion of the sur¬ 
face of the body may finally thus be involved. vitiligo in a negro boy 
The most common seats of the disease are the (Piffard’s case), 

face, the neck, the backs of the hands, and the 

extremities; and in these, since the course of the disease is exceedingly 
slow, there may be for years no apparent extension of any involved 
area. Upon the backs of the hands the disfigurement is usually more 
conspicuous at some seasons of the year than at others, a circumstance 
which probably explains the reported instances of recurrence and total 
disappearance of the disease in successive years. These changes are 
in part due to the influence of the sweat in washing the pigment to 


1 Louisville Med. News, 1880, x.p. 148. .. 

2 Receuil de Mem. de Med. de Chirurg. et de Pharm. mil., 1865. 


492 


DISEASES OF THE SKIN. 


the surface. Such an effect would, of course, render the hyper-pig¬ 
mented peripheral zone of a vitiliginous disk much the more con¬ 
spicuous. 

The health of the subjects of this disorder is usually unimpaired. 
A morbid mental condition is often produced when the disfigurement 
reaches the facial region, especially in women of middle life. 

As in several of the other pigmentary disorders of the skin, the 
patches of vitiligo may be symmetrical in distribution, with their out¬ 
lines limited to the areas supplied by certain nerves. Lesser, however, 
attributes this peculiarity to the anatomical relations of the skin in 
symmetrical regions of the body, an explanation which will not suffice 
for all cases. 

The course of the disorder is evidently toward the increase even 
where all the pigment is not removed from the surface. Generally a 
term is reached beyond which the atrophy does not progress. In 
exceptional cases the parts which have lost their pigment again ac¬ 
quire it. 

Patients of lymphatic temperament and blonde complexion (often 
they are women in early adult life) will occasionally apply to a physi¬ 
cian for relief of dark patches on the skin of the face. Examination 
of these faces often discloses faint lines, ribbons, or streaks of pigment 
about one or both cheeks, the temples, or the lips. But a yet more 
careful scrutiny recognizes an undue whiteness of the skin, with exceed¬ 
ingly faint and irregular outline near or next to these pigmented por¬ 
tions of which complaint is made. These cases are probably instances 
of vitiligo, even though they rarely exhibit the definite roundish con¬ 
tour of the typical patch of the disease. 

The decolorized patches are usually most conspicuous in summer; 
in other cases they are more manifest in winter. These peculiarities 
may depend upon changes either in the pigmented or unpigmented por¬ 
tions of the skin. 

Etiology. Vitiligo occurs in both sexes, and in individuals of all 
complexions and ages; though it is commonly observed among women 
and in early or middle life. It is at times coincident with sclero¬ 
derma, lepra, variola, and other diseases with similar cutaneous symp¬ 
toms, though it occurs independently of all such. Its etiology must 
be regarded as obscure, unless the strong probabilities in favor of its 
occurrence under the influence of perturbed innervation be accepted as 
conclusive. The disorder is of more frequent occurrence than derma¬ 
tological statistics tend to show. Many persons who are the subjects 
of vitiligo of an inconspicuous part of the body do not consult a 
physician with regard to the nature of the disease, as it occasions no 
physical distress. Close observation of the people with whom one 
comes in contact in public will often verify this fact. 

Pathology. The pathological anatomy of vitiligo may one day be 
described in the changes which occur in the trophic nerves supplying 
the skin. At present the cutaneous changes alone are recognized; 
and they are, as regards the pigment, neither strictly atrophic nor 
hypertrophic. It is true that there is an apparent atrophy in one por¬ 
tion of the skin, and an apparent hypertrophy in another; but this, 


ATROPHIES. 


493 


in cases falling short of complete pigment atrophy, may be merely a 
dystrophia or ataxia of the epidermis, a disturbance of arrangement 
and distribution, as of the blood in the face in certain cardiac diseases, 
when the skin is temporarily streaked or mottled by the irregularity 
in the distribution of the circulating fluid. Under the microscope no 
change is recognized in the skin beyond the absence of pigment. 

Diagnosis. Hutchinson, of London, devoted an entire chapter in 
his Lectures on Clinical Surgery 1 to the importance of the diagnosis 
between leucoderma and white leprosy; yet it seems incredible that 
the symptoms characteristic of a systemic disease could be confounded 
with those described above, where there is no cutaneous anesthesia 
nor structural change in the integument. This latter is, in fact, the 
basis of discrimination between all purely pigmentary and all non¬ 
pigmentary changes in the skin-color, separating them widely from para¬ 
sitic diseases (tinea versicolor), morphea, lepra, and syphilis. From 
the chloasmata, which are always accompanied by hyper-pigmentation, 
vitiligo is readily differentiated. 

Treatment. Much chagrin will be saved both physician and patient 
by practically regarding vitiligo as not amenable to treatment. Pa¬ 
tients occasionally recover while under treatment, which, however, has 
generally contributed but very little to the result. Arsenic and iron 
internally, recommended highly by some authors, have repeatedly failed 
to accomplish any appreciable results as regards dyschromia. By 
efforts directed to the removal of the hyper-pigmentation in the border 
of the achromic patches the disfigurement may be somewhat lessened. 
The method of arriving at this end is described in connection with the 
treatment of chloasma. It is possible that further experimentation 
with hypodermatic injections of pilocarpin, that have in a limited 
number of cases been followed by disappearance of the disease, may 
warrant a less unfavorable view of the results of treatment. 

Prognosis. The health of the subject of the nialady is not impaired. 
The disease is practically incurable, progressing usually until it has 
obtained a maximum of development; and then, as a rule, remaining 
unchanged throughout life. 


[D] Canities. 

(Lat. canus, white.) 

(Trichonosis Cana, Poliothrix, Hoariness, Poliosis.) 

Canities is that condition of the hairs in which they become in various degrees 
decolorized as the result of atrophy of their pigment. 

Symptoms. In this anomaly the hairs appear in all shades of white¬ 
ness, from dirty-gray to silvery-white, and this is either a general 
or partial, congenital or acquired, physiological or pathological, pre¬ 
maturely, rapidlv, or gradually acquired condition. General congen¬ 
ital whiteness of" the hairs is seen in albinismus, where pigment has 


i Churchill, London, 1878. 


494 


DISEASES OF THE SKIN. 


never been supplied to the filaments. Partial congenital whiteness is 
occasionally seen in meshes, limited in size and varying in color from 
pure white to a deeper hue, that from birth refuse to receive pigment in 
due proportion, thus contrasting strangely with the pigmented filaments 
by which they are surrounded. 

Physiological decoloration of the hairs in variable shades is the well- 
known result of advancing years. When premature, it may be con¬ 
sidered as resulting from pathological causes, or be due to other 
individual or inherited peculiarities. It may occur gradually or sud¬ 
denly; in the former case the hairs usually pass through varying 
shades of gray to white, and this at any period after (occasionally before) 
puberty, though usually after middle life is reached. Recurrence to the 
darker shades is rarely noted. Leonard, of Detroit, 1 cites a number 
of curious instances in which changes of this sort have occurred. 
Generally, however, canities of advanced years is progressive and per¬ 
manent, occurring earliest on the temples and the beard of man, then 
involving the vertex of the head. Finally, the hairs of the entire 
body-surface undergo similar pigmentary loss. 

It should be remembered that the coloring of the hairs of the head 
is, to a greater extent than is commonly appreciated, subject to varia¬ 
tion from the operation of external causes. Thus, washing the hair 
with alkaline solutions has a bleaching effect, while profuse sweating, 
inunction with fats, subjection to smoke, and the temperature-changes 
of the summer, have the contrary influence,the last named being pos¬ 
sibly associated with increased sweating in the hot season. 

Cases of sudden blanching of the hairs, occurring, for example, in 
a single night, are sufficiently numerous and well authenticated to be 
admitted as among the rare possibilities of a clinical experience. Ner¬ 
vous disorders, both centric and peripheral, such as long-continued 
mental depression, melancholia, paralysis, neuralgia, and traumatism 
of nerves or of nervous centres, may be followed by more or less rapid, 
general or partial, and permanent canities. The same result may fol¬ 
low wasting disorders, such as typhoid fever, tuberculosis, syphilis, 
and malarial (Chagres) fever, in which cases, as distinguished from 
the others, properly pigmented hairs may eventually replace those 
which were white. It is well known that the first hairs springing 
from a patch of alopecia areata where repair is in progress are often 
white or whitish, and are replaced later by those of normal color. 

Landois has shown that many instances of suddenly occurring cani¬ 
ties depend solely upon the rapid appearance of air-bubbles in the hair- 
shaft, in excess of the average number. Hairs whitened in alternate 
patches, rings, nodes, or spots have been described by Landois, Karsch, 
Richelot, Spiess, and others. 

Etiology. Whitening of the hair may be senile in origin, in which 
case it is customary to declare it to be physiological; or be due to 
heredity; to deficient nutrition or innervation of the hair-follicles; to 
functional or organic nervous affections (fright, facial atrophy, etc.); 
or to local chemical action upon the hairs. Premature canities in 


The Hair, etc., Detroit, 1880. 


ATROPHIES. 


495 


young adults is often associated with the occupations of life, being 
much commoner in men who from necessity have the head habitually 
covered, and who yet lead sedentary lives. 

Pathology. The pigment*substance of the hairs is both cellular and 
intercellular in its distribution, and is supplied by the papilla. Decol¬ 
oration of the hairs may be due to failure of supply or to removal of 
pigment; to unevenness of the hair-surface (by which the light is 
refracted); or to air-bubbles between and within the fibre-cells. In 
senile and pre-senile decolorations there is commonly actual diminution 
of pigment, that has been ascribed to failure of the papilla to produce 
or transmit it. Sudden canities is ascribed to the sudden appearance 
of air-bubbles in quantity in the shafts of the hair. Alterations of 
color in the hairs are attributed to successive periods of activity and 
rest in the pigment producing function of the follicle. 

Treatment. McCall Anderson, while admitting that the treatment 
of canities is unsatisfactory, suggests, in cases of accidental pre-senile 
blanching, strict attention to the general health, arsenic internally, and 
local stimulation, as in alopecia simplex. But the chief means of rem¬ 
edying premature canities is by the action of dyes, which are, in the 
main, compounded by solutions of nitrate of silver, acetate of lead, 
and sulphate of iron. The chief objections to their use are the dis¬ 
agreeable coloring of the scalp which results from incautious use of 
the dye, and the consequent liability to irritation of the surface. When 
applied to the hair alone these substances are not known to have a 
deleterious effect upon the health. Kaposi gives the following formula 
for hair-dyes: 

To obtaiu a black color— 


R.—Argent nitrat., 

gr. xy; 

Ammon, carb., 

gr. xxij ; 

Unguent, adipis, 

Ej ; 

or 

R.—Argent, nit., 

33 ; 

Plumb, acetat, 

gr. xv ; 

Aq Cologn., 

gtt. xv ; 

Aq. ros., 

ad f^iij ; 

To obtain a brown shade— 

R. —Acid, pyrogall., 

gr. xv; 

Aq. Cologn., 

3 ss; 

Aq. ros , 

3jss; 


1 

1 5 
32 


M. 


4 

1 

1 

96 


M. 


1 

2 

48 


M. 


Anderson first applies a lotion of bichlorid of mercury, 2 grains 
to the ounce (0.133 to 32.), and follows this with a solution of hypo¬ 
sulphite of sodium, 1 drachm to the ounce (4. to 32.), for the pro¬ 
duction of a jet-black shade. 





496 


DISEASES OF THE SKIN. 


2. ATROPHIES OF HAIR. 

ALOPECIA. 

(Gr. dAo)7r^, a fox.) 

(Calvities, Defluvium Capillorum, Deficiency of Hair, 
Baldness. Ger., Kahlheit.) 

Alopecia is a physiological or pathological, symmetrical or asymmetrical, partial or 
complete deficiency of hair. 

This condition may be due to arrested pilary development at birth, 
or to any cause interfering with the regular physiological process by 
which hairs are constantly shed and replaced by new filaments. 

The simple tqrm alopecia is no longer descriptive of a disease, but 
only of a symptom, loss of hair, which occurs in a large number of 
morbid and even physiological states, the classification of which, with 
respect to alopecia, is differently planned by different authors, but most 
are substantially agreed upon the following divisions : 

In a first class are named the forms of baldness depending upon 
general conditions of the system, physiological or pathological; among 
the former are the congenital, pre-senile, and senile varieties; among 
the latter are those due to all causes producing debility, anemia, and 
defective nutrition. In this last group are named the alopecias of 
tuberculosis, erysipelas, syphilis, carcinoma, diabetes, and malarial, 
chemical, and other intoxications. 

In a second class are included the alopecias due to local scalp affec¬ 
tions, including two groups: those, first, in which the baldness is an 
epiphenomenon of the cutaneous malady (Brocq), such as the loss of 
hair incidental to pemphigus foliaceus, exfoliative dermatitis, sclero¬ 
derma, lupus erythematosus, and pityriasis rubra; those, second, in 
which the hair-loss is the chief morbid symptom: (a) alopecia furfur- 
acea, and the group of disorders which may be represented by that 
name, the seborrheas, the seborrheic eczemas, etc.; ( b ) alopecia areata, 
which eventually may be included in the first class as a hair loss due 
to centric nervous changes; (c) an indeterminate and ill-recognized 
group, in which folliculitis is a distinguishing symptom; and ( d) the 
alopecias due to vegetable parasites. 

Many of these several affections are discussed in the chapters of this 
work specially devoted to each. In the pages which follow attention 
is particularly directed only to those special forms of alopecia usually 
separately considered, because it is the deformities resulting from these 
forms for which the practitioner is most commonly consulted. 

Congenital Alopecia. In rare cases there is a partial or a com¬ 
plete absence of hairs at birth, in consequence of an arrested develop¬ 
ment of the pilary system. Generally, however, these appendages of 
the skin are merely of tardy appearance, their eruption being extraor¬ 
dinarily delayed, as in cases of retarded dentition. 


ATROPHIES. 


497 


When this condition persists to adult years, as is very rarely the case, 
neither hairs nor teeth may be formed, as in Danz’s observation. A 
child seven years of age has been presented at the clinic, with only 
a small wisp of white hairs upon the vertex of the scalp. 

In localized congenital alopecia hairs rarely develop after maturity, 
and here, also, abnormalities of teeth may be coincident features. In a 
case of congenital alopecia examined by Schede 1 the sebaceous glands 
were found opening on the free surface of the skin. In the deeper 
part of the cutis straight or convoluted hair-rudiments were visible in 
the tubules, without perceptible internal cavity, which corresponded 
with the external root-sheath. 

Senile Alopecia. The baldness of old age, whether occurring 
upon the vertex so as to produce a tonsure like that of the priest, or 
whether limited to the frontal region, or so extensive as to involve 
nearly the entire calvarium leaving a fringe of hairs at the occiput 
and temples merely, is always remarkable for its symmetry. There 
is, hence, a certain degree of dignity added to the appearance of the 
head that an asymmetrical loss of hair could not produce. It may 
occur at varying ages of advanced life, and is quite frequently trace¬ 
able to an early seborrhea sicca or alopecia furfuracea. It is much 
commoner in men than in women, largely because of the difference in 
the manner of covering the head in the two sexes, women usually 
wearing an exceedingly light dress for the head, while men encase the 
latter with tight-fitting caps or hats which interfere with proper aera¬ 
tion of the scalp. Individuals of the male sex, also, in consequence 
of their usually wearing the hair short, bestow far less time upon the 
care and dressing of it. In uncivilized races, where these differences 
are less marked and where men pay great attention to the ornamenta¬ 
tion of the scalp, senile baldness is of less frequent occurrence. 

The bald surface, as a rule, is smooth and shining; it is occasionally 
the seat of a seborrhea oleosa. The hair-follicles, with their accessory 
sebaceous glands and occasionally the skin itself, are often in a state of 
atrophy, though there may be dilatation of the sebaceous glands. 
There is commonly some blanching of the hairs, which are gradually 
shed, as also of those which remain, though this is not constant. These 
conditions are much less frequent upon the surface covered by the beard 
and pubic and axillary hairs, where, according to Michelson, the hairs 
in advanced years are often denser than at other periods of life. 

Premature or P re-senile Alopecia, or premature calvities, is 
that form of acquired baldness which occurs in individuals who have not 
attained advanced years. It may be either idiopathic or symptomatic. 

The idiopathic variety does not originate in the diseases of the scalp 
or of the general economy that are recognized as effective in the pro¬ 
duction of other forms of baldness. It is, as with senile alopecia, 
more common in men than in women, and is in the former sex decid¬ 
edly prevalent among those leading sedentary lives. The loss of hair 


1 Arch fUr klin. Chir., Bd. xiv. 
32 


498 


DISEASES OF THE SKIN. 


may be produced either rapidly, or, more commonly, slowly, and at 
any period after the puberal epoch. The pilary growth may gradually 
and evenly recede from the forehead, or, what is more frequent, recede 
on either side of the median line leaving a more vigorous crop extend¬ 
ing centrally toward the root of the nose, or produce the effect of the 
tonsure described above. It is always symmetrical and usually rem¬ 
ediless, partial calvities being the permanent result of the process. In 
many families there is a predisposition to this premature loss of hair 
that may be recognized in the males of succeeding generations. 

Symptomatic premature alopecia is the frequent result of a series of 
local and general disorders which vary in their gravity. Sudden and 
gradual symmetrical thinning of the hairs or complete baldness is 
sufficiently common as the result of seborrhea sicca, psoriasis, and other 
cutaneous affections of the scalp; the asymmetrical forms being more 
common in asymmetrical scalp diseases, such as those resulting from 
the destructive action of the vegetable parasites. Rarely, however, 
asymmetrical seborrhea, occurring in patches upon the side of the head, 
may produce this disfigurement. Among the systemic disorders which 
have this effect may be named almost all severe febrile processes 
including the exanthemata, profound disorders of the nervous centres, 
lepra, and syphilis. In the last-named disease it may occur as a pre¬ 
cocious or a tardy symptom, the former being always symmetrical, 
variable as to the degree of loss, rarely so severe as to cause baldness, 
and, occurring as it does usually in early adult years, generally quite 
remediable. The tardy form is usually associated with the evolution 
or destructive involution of gummata of the scalp, and resulting bald¬ 
ness is often permanent. 

The forms of alopecia described above as encountered upon the 
scalp may involve also other hairy portions of the body, as of the 
axillae and the pubes; and these also in variable degrees. 

Pathology. In senile and premature alopecia, a fibrous endarteritis 
is described by Michelson as first occurring to narrow the lumen of 
the vessels, that starves the follicular and perifollicular tissues until 
an atrophy results. The epidermis becomes thinned; the derma con¬ 
tracts; the hair-follicles shrink, while their funnel-shaped orifices, 
occupied with loose horny masses or lanugo-hairs, remain patulous. 
Convolutions of pigmented, roundish nuclei, aborted results of hair- 
formation, may rarely be recognized at the base of the empty hair-sacs. 
The coil-glands and sebaceous glands and the muscles are but slightly 
altered. 

Treatment. The treatment of alopecia in general is that which stim¬ 
ulates the nutrition of the hair-follicle by producing in its periphery a 
species of transitory and artificial hyperemia. This condition is usually 
accomplished by friction of the scalp with a brush, aided by the local 
employment of one or more of the alcoholic, oily, alkaline, and other 
stimulating applications described below. The general health must, in 
these cases, receive special attention. A large number of individuals 
suffering from premature baldness have a distaste for fat; and the 
ingestion of cod-liver and other nutritious oils, fat meat, or linseed 
and linseed oils, as recommended by Sherwell, is for such patieuts 


ATROPHIES . 


499 


advisable. Iron, strychnin, tar, phosphorus, and arsenic often meet 
the indications presented. 

A scanty crop of short, soft, downy hairs may, however, push for a 
time to the surface, but they soon yield before the inactivity of the 
follicles in which they are implanted. Inasmuch, however, as excep¬ 
tionally brilliant results are occasionally obtained by treatment, the 
latter is always deserving of a trial. When the alopecia is symptomatic 
of some local disease of the scalp, the Jatter, of course, is first to be 
relieved by the measures appropriate for each, as, for example, the use 
of parasiticides in diseases of parasitic origin. The total or partial 
symmetrical losses of hair occurring in the course of systemic dis¬ 
orders have a much more hopeful prognosis. Exception, however, 
is to be made of the tardy syphilitic alopecia associated with local 
scalp-lesions or profound cachexia. In all forms of syphilitic alopecia, 
local as well as constitutional treatment is indicated. 

Local treatment may often be preceded by shampooing with either 
the Sarg fluid soap, or combinations of glycerin, alcohol, and sapo 
viridis to meet the requirements of individual cases. The scalp, after 
all such shampooings, should be anointed with lanolin, plain or sali- 
cylated; vaselin; the oil of benne; or scented castor oil. In obstinate 
cases the nail-brush may vigorously be used over insensitive scalps at 
the time of the shampooing. The salve used may often be advan¬ 
tageously medicated with sulphur, chrysarobin, tar, cantharides, or 
mercury. Formulae for lotions and salves to be used in this way are 
appended: 


R.—Hydrarg chlorid. corros., 

gr. v; 

ij; 


33 

Spts. vin. rectif., 

64 


Glycerin., 

|ss; 

16 

M. 

Aq. ros., 

For external use over the scalp. 

5 v j ; 

192 

R.—Picis liquid, [vel.ol. rusci,] 
01. lavandul., 

J>aa 3j; 

4 


01. pin. sylvestr., 

Ey j; 

192 

M. 

[Piffard.] 

R.—Hydrarg. chlorid. mit-, 


5 

66 

Hydrarg. ammon. chlor., 


2 

Vaselin., 

ad 3j; 

32 

[ 

M. 

Bronson.] 


R.—01. sabinse, 

Spt. vin. rectif., 


gtt. v-ixx; 

3j; 


183-2. 

321 M. 
[Pincus.] 


R —Hydrarg. bichlorid., 
Cantharid tinct., 
Medull. bovis, 

01. rosse, 


gr. 


fjj; 


q. s. : 


032 

4 

16 

M. 

[Van Harlingen.] 


R.—Acid chrysophanic., 
Glycerin , 

Vaselin., 


gr. x ; 


Wxi; 
3 vij; 


M. 


[Anderson.] 






500 


DISEASES OF THE SKIN. 


R.—Sulphur, praecip., 
Ungt. aq. ros., \ 
Yaselin.j J 


3j; 

aa ^ss; 


4 

16 


M. 


Andre is said to have induced an'abundant growth of hair in an 
obstinate case of total baldness by hypodermatic injections of the 
muriate of pilocarpin, from -J- to J ( 0 . 008 - 0 . 016 ) of a grain being 
injected on each occasion. 

The treatment of alopecia is largely that of alopecia furfuracea and 
alopecia areata. 


Alopecia Furfuracea. 

(Pityriasis Capitis, Alopecia Pityrodes Capillitii.) 

Under this title is included that loss of hair, varying greatly in 
degree from moderate thinning of the growth to considerable sym¬ 
metrical baldness, usually of the vertex, which accompanies the pity- 
riasic forms of seborrhea or dermatitis seborrhoica of the scalp. It is 
exceedingly common, especially in men. 

The disorder, essentially chronic in course, is usually first manifested 
in early adult life, though persons of both sexes, from twelve to fifteen 
years of age, may at these ages display typical forms of the disease. 
After some months or years the subject of the affection discovers a 
relatively large loss of hairs from the scalp, producing thinness of the 
growth upon the vertex, near the brow, or over the temples. The hairs, 
when examioed in situ upon the scalp, are shortened and rebellious to 
the comb and brush, projecting stiffly from the brushed surface, being 
also harsh, lustreless, and rarely well anointed with sebum. Those shed 
from the scalp, especially of men, are found to be nearer in type to the 
lanugo- or downy hairs than those which fall physiologically from a 
vigorous growth of hair in a healthy subject; that is, they are short, 
thin, pointed, and often with an indistinct medulla. 

At the same time the scalp is in process of incessant desquamation, 
the scales usually being of pityriasic type, and exceedingly abundant 
so long as the alopecia is not complete, after which the epidermal catarrh 
promptly disappears. The mealy, bran-like scales are shed in a fine 
shower upon the clothing of the patient, and, the disease being more 
common in men than in women, its traces are often distinct upon the 
collar of the coat after the fingers have been passed through the scalp. 
The same flour-like, whitish and grayish scales are distinct and plen¬ 
tiful among the hairs to which they cling, and they can also be recog¬ 
nized over the scalp-surface when the latter is inspected with care. 
Itching is often marked; the scalp may be scratched and torn by the 
nails, and is, in some cases, reddened and thickened. Often the sebor¬ 
rheic element is more marked and the scales are thicker and greasy. 

For further consideration of the scalp symptoms and for the ques¬ 
tions of etiology, pathology, diagnosis, and treatment, the reader is 
referred to the chapters devoted to Seborrhea and to Dermatitis Sebor¬ 
rhoica, of which disorders this form of alopecia is a result. 



ATROPHIES. 


501 


Alopecia Areata. 

(Lat. area, a vacant space [ arere, to wither, Fox].) 

(Porrigo Decalvans, Tinea Decalvans, Area Celsi, Area 
Johnstoni, Alopecia Circumscripta. Fr., Pelade.) 

Statistical frequency in America, 0.749. 

Alopecia areata is a disease of the pilary follicles characterized by the sudden occur" 
rence of general and symmetrical, or partial and asymmetrical baldness, the latter 
exhibited in distinctly circumscribed, smooth, whitish patches, which are, in 
typical cases, completely destitute of hair. 

Two forms of this disease occur, that form in which the baldness 
develops in patches, and that in which there results either rapidly or 
slowly a generalized loss of hair. The latter may begin with display 
of circumscribed patches, or the loss of the pilary filaments may almost 
from the first be both general and symmetrical. By some authors these 
two varieties are regarded as separate affections. 

Symptoms. This disorder, which is more common than is generally 
believed by physicians, may, in some cases, at its outset be preceded or 
be accompanied by symptoms of ill-health, such as headache, malaise, 
inappetence, loss of flesh, or malnutrition. In other cases, cephal¬ 
algia, paresthesia, pruritus, and formication of the skin of the scalp 
and other regions indicate some disturbance of the nervous centres. 

Often, however, patients of this class are in sound health, the dis¬ 
ease then manifesting itself by the sudden and complete loss of hair 
over a circumscribed patch, usually upon one side of the scalp, so 
rapidly effected that a first discovery of the fact may be made at 
the toilet of the morning. After a variable period of time other 
patches of baldness may occur, all the hairy portions of the body being 
liable to the affection, the scalp first in order, next the beard, then the 
genitalia, axillae, brows, eyelids, and the general surface of the body. 
In early childhood cases occur in which the closest scrutiny with a 
glass fails to detect a single filament of hair upon any portion of the 
skin. 

The patches may be roundish, ovular, or irregularly shaped, and 
may vary greatly in size, from that of a small coin upward. They may 
be so numerous as to disfigure the entire scalp, and though they touch 
at the borders when thus numerous, they can scarcely be said to coal¬ 
esce, as the individual elementary areas are usually recognizable. Their 
surface is smooth, whitish, and often perfectly destitute of hairs; it is 
rarely tumid and slightly reddened. The hairs at the periphery are 
usually of full length and may be fixed in situ, but they are occasion¬ 
ally fragile, and, as a rule, are readily withdrawn from their follicles. 
Stumps of such friable and loosened hairs at times may be seen at the 
margin of the patch. In point of abnormal subjective sensations, tem¬ 
perature, or disease of the surface from which the hairs have fallen, 
there is, as a rule, complete absence of symptoms. The skin, when the 


502 


DISEASES OF THE SKIN. 


evolution of the disease is complete, is usually normal to the touch 
and pliable. Occasionally it is anemic, thinned, and more movable 
over the pericranium than in the portion of the scalp which is not the 
seat of the disease. 

In incomplete evolution and in periods of repair, downy hairs may 
appear upon the surface, at times considerably differing in color from 
those springing from unaltered regions of the scalp. 

The loss of hair from the affected surface may rarely be gradual, be 
preceded by mild pruritus (Besnier et Doyon), or be followed by anes¬ 
thesia (Neumann). Its apogee once attained, the course of the disease 
is variable; it may persist for periods without apparent change; or 
new patches may form while those of an older date either proceed to 
exhibit wholly or in part the pilary growth; or, this latter accom¬ 
plished, may suffer a fresh loss by relapse. Shifting areas of baldness 
may in this manner invade the entire surface of the scalp, which yet 
at any one moment of time exhibits a loss of but the half of its hirsute 
covering. 

The variations exhibited by the disease in its evolution are numerous, 
but they rarely mask its special features. The hairy loss is usually 
first apparent on the scalp; but it may first be conspicuous over the 
region of the beard in the male subject. Though the larger-sized 
patches, formed by coalescence of several of the smaller, may form 
with relative rapidity, the condition once fully developed may remain 
for weeks and even for months apparently unchanged. At the periph¬ 
ery the hairy filaments may be short, straight, very loose, and exhibit 
at the bulb a spade-like extremity or an attenuated point, the non- 
atrophied shaft thus contrasting with the wasted portion implanted 
below the cutaneous level; or, especially when repair is about to set 
in, the hairs at the border of the patch may firmly be fastened in situ. 
When the filaments begin to reappear over the bald patches there is 
commonly a fine downy growth over the affected area, later replaced 
with a crop of thicker and stronger whitish filaments, which are 
always succeeded, in cases terminating favorably, by a growth of hairs 
as well colored, as vigorous, and as persistent as any which were at 
first lost. An odd appearance is often presented by patients who are 
improving, when the strong aud white new hairs contrast vividly in 
color with the dark shade of those on the unaffected scalp. 

When the disorder becomes universal this result may be reached 
rapidly or very slowly, and this either after the persistence (or the 
reverse) of the disease in patches. This variety (or complication) of 
alopecia, which is fortunately rare, usually occurs if at all after the 
middle period of life, but it may develop in the very young. 

Variations occur also in the appearance of the patch. Usually it is 
compared in appearance with the whiteness and smoothness of a billiard- 
ball. At times, for a brief while, it is seen covered with stumps of 
friable and fallen hairs. Again, hairs are left which the French 
describe as “ cadaverized ” (dead), and which are merely retained in 
place by mechanical adherence. In other cases the surface is tumid, 
reddened, and even hyperemic. It is not very rare to discover alopecia 
areata in patches which are also the seat of the vegetable parasites. 


ATROPHIES. 


503 


A gentleman, long psoriatic, under our observation exhibited a typical 
seborrhea capitis and later developed a no less typical alopecia areata. 

The course of the disease in young subjects is usually toward a favor¬ 
able result. There is hope, as a rule, when even the downiest and 
thinnest growth, requiring a good light and a glass for its recognition, 
can be appreciated. Even when so feebly attached that these filaments 
are removed with ease by the fingers or a brush, and when they spon¬ 
taneously fall they may be replaced by crop succeeding crop of stronger 
filaments, which eventually persist. In all serious cases, usually after 
the forty-fifth year of life, there is absolute atrophy of the hair-follicles 
and a resulting remediless baldness. 

There is some reason for believing that the disease has a relatively 
fixed period of evolution, though the exact limits of the period are not 
known. Few individuals suffer for less than one year; the most are 
relieved within a period of two years. These remarks, however, 
apply to the asymmetrical forms of the disease in the relatively young. 
The symmetrical alopecia areata of the middle-aged is a far more for¬ 
midable affection. 

Few diseases are the source of greater mental distress than those of 
the class now under consideration. The prominent deformity thus 
occasioned debars the subject of the malady from social relations of 
many kinds, and this intensifies the morbid feeling which every reflected 
view of the head awakens. This fact is particularly true of women. 
The successful management of these cases calls often for the support¬ 
ing assurances of the practitioner. 

Etiology. The question of the parasitic or neuropathic origin of 
alopecia areata is still undecided, though it has been the subject of 
extended discussion and observation. It is highly probable that many 
of the limited, asymmetrical forms of the disease, in which the patches 
increase by peripheral extension, are due to parasites not yet recognized. 
Eichhorst, Thin, Von Sehlen, 1 Robinson, 2 and others have discovered 
in affected patches and about the bulbs of hairs in alopecia areata, 
micro-organisms which have even been cultivated in generations, but 
which have not yet been shown to be effective in the production of 
the disease ab novo. Yet, as if to demonstrate the efficacy of some 
such agency, not a few outbreaks of the disease have been reported 
both in France and in America, where entire companies of a regiment, 
or numbers of inmates of public institutions, have suffered from the 
disease in an apparently contagious form. It is, however, noticeable, 
as Besnier and Doyon have shown, that in these instances neither 
the hairs themselves nor their sheaths exhibit any of the changes com¬ 
monly recognized as the result of parasitic invasion, in the way of 
splitting, Assuring, peeling of cuticle, or irritation. There is in all 
but one picture, it is that termed by the French “ cadaverization.” 
The hair-bulb is simply desiccated, shrivelled, and wasted. 

The weight of evidence in favor of a neuropathic origin of some 
cases of the disorder, however, is great and very generally accepted 

1 Annal. de Derm, et de Sypb., June, 1886. 

2 Monatschft. f. prakt. Dermat., 1889, vii. p. 409, 


504 


DISEASES OF THE SKIN. 


by authorities. Mental emotion (anxiety, fright), anemia, innutrition, 
traumatism both general and local (falls upon the head, blows inflict¬ 
ing lacerated wounds of the scalp), and bodily injuries of the general 
surface have all been cited as effective. 

It occurs with equal proportion in the two sexes, and among these, 
irrespective of social condition. Of the partial and asymmetrical 
forms, the larger number of cases occur in young subjects, from child¬ 
hood to early adult life. The severe and generalized forms are more 
often encountered in middle-aged persons. In the latter class espe¬ 
cially it is occasionally observed to follow the obscure disorders of the 
nervous centres due to sudden or prolonged undue excitation. In 
young subjects one may often discover a peculiar repugnance to the 
ingestion of fat and meat, a point to which attention is called in con¬ 
sidering alopecia simplex. 

The neurotic explanation of the generalized and symmetrical forms 
of this disorder is more generally accepted as facts accumulate bearing 
on its etiology. The nervous symptoms which often precede or accom¬ 
pany the appearance of the bald patches are strikingly suggestive, 
and have led Von Barensprung to announce his theory of u inherited 
innervation” as a cause of the malady. Further, the occurrence of 
the disease after shock of the nervous centres is significant. Max 
Joseph produced baldness in patches upon the ears of cats and rabbits 
by section of the second cervical nerve near the intervertebral gan¬ 
glion. 

Collier 1 cites two cases in which alopecia areata followed a blow upon 
the temporal region, and Sir Dyce Duckworth reports the case of a 
gentleman who sustained an injury to the head in a fall from a dog¬ 
cart, and who suffered as a result from permanent loss of hair. Overal 2 
reported a similar instance. 

Pathology. The anatomical lesions which produce alopecia areata 
have not been recognized. The hairs fallen from the surface, when 
examined with the microscope, are seen to be atrophied in the bulb 
and shaft, though Rindfleisch describes in certain cases a node-like 
enlargement of the hair-shaft after its escape from the follicle. Frac¬ 
ture of the shaft is in some cases also noted, evidently an accident of 
the process. A large number of micro-organisms beside those observed 
by the authors cited above, and by Feulard (Teignes et Teigueux, 
Paris, 1886), Schiitz, 3 and Plattner, 4 can be recognized upon the sur¬ 
face and about the hair-bulbs. In several cases spores and mycelia 
of the trichophyton have been seen in the hairs, a coincidence of dis¬ 
orders which has been observed by many. 

As a result of careful examination of many pathological sections, 
Giovannini 5 and Robinson 6 believe the disease is primarily an inflam¬ 
mation of circumscribed areas of the corium, and especially of the sub- 
papillary layer. In a small patch of one week’s duration Robinson 
found marked perivascular cell-infiltration in a limited region of the 
corium, the papillae being but mildly affected, while the epithelium, 


1 Lancet, American Edition, August, 1881, p. 130. 
8 Monatschft. f. prakt. Derm., 1887. 

5 Annal. de Derm, et de Syph., 1891, p. 921. 


2 Alien, and Neurol., St. Louis, 1886. 
4 Inaug. Diss. Chirur., 1890. 

3 Morrow’s System, vol. iii. p. 865. 


ATROPHIES. 


505 


rete, subcutaneous tissue, and glands were normal. Some of the hair- 
follicles were normal, while in others no papillae could be found, and 
the hairs were wanting or imperfect. In cases of longer standing 
evidences of inflammation were more marked and extensive, and there 
were vessels with thickened walls and narrowed lumen. In some cases 
there was more or less atrophy of all elements of the corium, with 
destruction of the hair-follicles and sebaceous glands. Giovannini, who 
describes an invasion by leucocytes of the hair-follicle, would consider 
the process a deep-seated folliculitis. 

In default of more positive knowledge on the subject, many derma¬ 
tologists have assumed the disease to be a trophoneurosis, a view sus¬ 
tained by the etiological history of certain cases. 

Diagnosis. Alopecia areata is to be distinguished from vitiligo of 
the hairy portions of the surface by the preservation of the pilary 
growth in the disease last named, the filaments moreover, having 
usually a blanched and whitened look, due to the absence of pigment. 

From ringworm and favus of the scalp the disease in question is 
readily differentiated by the suddenness of its onset; the absence of 
stumps of hairs, scales, crusts, and evidences of irritation in the 
involved area; the whiteness, smoothness, and complete baldness of 
the latter; and, above all, by the failure to detect with the microscope 
the evidence of the presence of a vegetable parasite. 

The asymmetrical patches of seborrhea of the scalp are recognized 
by the presence of the fatty plates pasting the hairs to the scalp-sur¬ 
face, as well as by the slow and very gradual onset of the disorder. 

Other forms of baldness than those named above are all of gradual 
and, in their early stages, of symmetrical development. Those result¬ 
ing from traumatic injuries of the scalp, with cicatricial results, are 
easily determined as having such an origin. 

Treatment. One necessarily views with some distrust all treat¬ 
ment for that disease which in the course of months or years usually 
terminates in spontaneous recovery, and in the meantime may bid defi¬ 
ance to each and every therapeutic measure. Nevertheless, persistent 
and hopeful management of even the apparently desperate cases is 
occasionally rewarded by such brilliant consequences that, however 
slight may be the foundation for a belief in the value of the therapy 
employed, it deserves recognition and trial. 

The hygienic management of every case is a matter of great impor¬ 
tance. Tobacco in every form should be denied to subjects of the 
disease addicted to its use. Iron, quinin, nux vomica, cod-liver oil, 
phosphorus and the hypophosphites, arsenic, and strychnin are often 
indicated, and used with great benefit. 

The general condition of the patient affected with this disease is 
always to be considered. Where ferruginous and other tonics are 
indicated the general tone of the nervous system is always to be con¬ 
sidered. There are few patients who do not require daily salt-and- 
water bathing of the entire body-surface, followed by brisk friction, 
especially over the spinal region. In the case of children this treat¬ 
ment must be practised by a skilled hand. When practicable the cold 
douche is even to be preferred. 


506 


DISEASES OF THE SKIN. 


In all cases of implication of the head, where the scalp is involved 
in either sex, and where the peculiar hypochondriasis of the disease 
is developed, a wig should be worn for the sake of its moral effect 
upon the sufferer. Its use, however, should be limited to social occa¬ 
sions, visits, etc., as the persistent wearing of a peruke indoors seems 
to lengthen somewhat the course of the disease. 

The indication for local treatment is to destroy any parasites that 
may be present and to increase the physiological afflux of blood to the 
hair-follicles. With this end in view the affected parts are to be bathed 
daily in water as hot as can be tolerated, then dried, and scrubbed with 
a stimulating lotion. The articles usually employed are alcohol, ether, 
resorcin, turpentine, ammonia, camphor, cantharides, carbolic acid, oil 
of mace, croton oil, tincture of nux vomica, tincture of capsicum, 
tincture of aconite, castor oil, tar, iodin, sulphur, and the mercurials. 
All frequently fail. Several of these substances in combination seem 
at times to be of service. 

The following is a formula, the ingredients of which may be varied 
to suit the indications in different cases: 


-01. ricini, 

f^ss; 

16 

Acid carbolic., 

; 

4 

Cantharid. tinct., 


16 

01. rosmarin., 

gtt XV; 

1 

Spts. vin. rectif., 

ad f % iv; 

128 


Sig—For external use over the scalp with friction. 

The preparations containing sulphur, resorcin, chrysophanic acid, 
bichlorid of mercury, etc., given on a preceding page in connection 
with the treatment of seborrhea capitis, are often valuable. 

Nevins, of Liverpool, mops the entire scalp-surface with strong 
liquor ammonise. Speedy return of hair in a patch of alopecia areata 
has followed a single application of pure creosote to the denuded sur¬ 
face, resulting in moderate vesication. The spirit of turpentine and 
pure carbolic and acetic acids have similarly been employed; but all 
these caustic applications are to be used with excessive caution. 

By many experts epilation is practised, so as to produce a zone of 
baldness about each patch, to the extent of removing all the loosened 
hairs at the periphery. By others, having in mind the parasitic origin 
of certain cases, shaving of such borders is substituted for epilation; 
by these, also, the remedies selected for application are of the order 
of parasiticides, for example, mercurials, sulphur and its compounds, 
chrysarobin, pyrogallol, and iodin. 

Repeated blisterings of the scalp with cantharidal collodion, spirit 
of green soap, and petroleum have also been employed externally with 
success. The ointment of chrysarobin has the disadvantage of staining 
not only the remaining hairs, but often also the face in consequence of 
the frequency of a transmission to that locality by the medium of the 
hands. When patients, however, consent to the use of chrysarobin it 
is worthy of a trial, as its application has speedily been followed by a 
vigorous growth of new pilary filaments. Andr6 employed ten hypo¬ 
dermatic injections of muriate of pilocarpin in J- grain (0.008) doses, 
which resulted, in the case of a middle-aged woman affected with total 



ATROPHIES. 


507 


symmetrical baldness, in an abundant growth of hair. Bichlorid 
of mercury has similarly been employed. 

Lassar and Bishop 1 operated by first vigorously shampooing the entire 
scalp daily for fifteen minutes with a strong solution of tar soap, rinsing 
next with an irrigator, by the aid of warm water, followed by cold 
water, and subsequently drying. Then a corrosive-sublimate wash 
(l.:300. adde spts. cologniens., glycerin., aa 100) was applied, and 
the head again dried; then a solution of naphtol (naphtol, 0.5; spts. 
dil., 70.; aq. dest., 30.) was rubbed in. Lastly, carbolized oil, 
per cent., was poured slowly over the scalp, entering the cleansed and 
expanded orifices of the glands, so that 7 drachms (28.) could be 
employed at a time. This course was pursued daily for eight weeks. 

Faradization of the scalp with a stiff-wire brush, pushed to the 
point of producing moderate hyperemia, has been followed by excellent 
results. 

Wilson recommends: 


R .—01. amygd. dulc., 

f 3j; 

32 


Capsici tinct, 

f.^ij ; 

8 


Liq. aramon. fort., 

f.lj; 

32 


Spts. rosmarin., 

fZv; 

160 


01. limon., 

f 3j; 

4 

M. 

Another stimulating application is: 



R.—01. terebinth , \ 

01. ricini, / 

aa f § ss ; 

16 


Origani tinct., 

01. camphorat., 

f 3j; 

4 


f.U; 

32 


Liniment, volatil., 

ad f^iij; 

96 

M. 

Sig.—For external use with 

a brush until the scalp is 

irritated. 


Shaving should regularly be practised when in men the region of 
the beard is involved, as the deformity is thus rendered somewhat less 
conspicuous ; and the bald surface should frequently be stimulated 
with one or several of the topical applications named above. Alco¬ 
holic solutions of resorcin (3 to 20 per cent.) or of mercuric bichlorid, 
J to 1 grain (0.033-0.066) to the ounce (32.), are to be well rubbed 
over the patch or patches once or twice daily. The disease in this 
locality may coexist with benignant syphilis, the latter disease pursu¬ 
ing a career considerably shortened by vigorous treatment, while the 
former, none the less, endures from twelve to fourteen months, long 
after the syphilitic cachexia has been relieved. At the end of this 
time recovery occurs precisely as in those cases which have presented 
no history of infection. 

Alopecia Neurotica. Under this title Michelson includes all 
cases of loss of hair (1) coincident with or following traumatism of 
cerebral or peripheral nerves, (2) those associated with diseases of the 
nervous system due to internal causes. As to the first class, instances 
of alopecia are given above, where, as in the case reported by Sir Dyce 
Duckworth, the loss followed a fall upon the head. Todd, Schiiltze, 
Fischer, and Michelson have also made observations of this character. 


1 Loc. cit. 




508 


DISEASES OF THE SKIN. 


In the second category are the local and general losses of hair reported 
as associated with melancholia, migraine, neuralgias of persistent type, 
and facial and other paralyses. In some of them the skin and panniculus 
adiposus have wasted, the hairs falling in stripes or ribbon-shaped 
streaks, with partial or complete canities of those left in the follicles. 

Prognosis. From what precedes, it will justly be inferred that, as 
regards the relief of the baldness, the asymmetrical development of 
alopecia areata in youth is much more favorable than the symmetrical 
general disease of middle life, the latter being often remediless. In all 
cases the practitioner should actively persevere to the end. In no 
case should any encouragement be given as to complete relief within 
the year, though such exceptionally short careers of the disease are 
at times observed. The prognosis of the same affection of the beard 
is quite favorable, the disease, in young men, usually concluding its 
stadium in the course of about one year, with a favorable termination. 


Alopecia Follicularis. 

(Folliculitis Decalvans, Folliculites et P£rifolliculites 
Destructives du Follicule Pileux, Folliculites et 
Perifolliculites Decalvantes, Alop£cies Cicatricielles 

IxNOMINEES, Acn£ DeCALVANTE, ETC.) 

A series of closely related yet differing forms of folliculitis and peri¬ 
folliculitis may involve the hair-follicle and its adjacent parts, destroy¬ 
ing not merely the hair-bulb, but also the hair-papilla. As a result these 
conditions are followed by permanent alopecia and by the production 
of scars. The inflammatory nature of the process is usually though 
not always apparent. There is commonly a marked tendency to group¬ 
ing of lesions, but they may be scattered and isolated. These disor¬ 
ders, studied with special care by French observers, are yet but 
imperfectly understood, and none is perfectly distinguished from the 
other dermatoses resulting in hair loss. 

They are usually divided into a first class with disseminate, and a 
second with grouped lesions. 

In the first class are included all affections of the hairy region of 
the body capable of producing suppuration and destruction of the hair- 
follicle. Here, as in the second class, are effective many of the micro¬ 
organisms which invade other portions of the skin. In the order of 
importance in this connection are to be named the staphylococci and 
the microbes of syphilis, variola, and lepra. In both classes there are 
lesions probably due to infection with tubercle-bacilli whose character¬ 
istic features will one day be fully recognized. 

In the second class are collected a number of disorders briefly named 
below where the lesions are aggregated in patches. They are all char¬ 
acterized by an inflammatory change in the follicles and perifollicular 
tissue, followed by destruction of the hair-papilla, a resulting remedi¬ 
less alopecia, and the formation of cicatriform tissue as a substitute 


ATROPHIES. 


509 


for the normal skin originally provided with follicles and hairs. Brocq 
includes in this class the disorders named below, many of them of 
great rarity; some observed by but few experts. 

(а) Cicatricial alopecias in small irregularly disseminated plaques. 
These can be recognized when any scalp which has been the seat of a 
severe alopecia pityrodes is minutely studied. They are probably acci¬ 
dental results of that morbid condition and are due to infection of the 
follicles with cocci. 

(б) Cicatricial alopecias of the scalp, the eyebrows, and the face, 
where minute glistening whitish points result, compared by Brocq to 
the lesions produced by the destruction of the hair-papilla in electrol¬ 
ysis. It is possible that these lesions are due to the cause suggested 
for the first group. 

(c) False alopecia areata (“ pseudo-pelade,” of French writers). In 
these cases the scalp about one or several hair-follicles becomes tumid 
and reddened. The hair is loosened in its pouch, and whether it fall 
spontaneously or be removed by epilation, it is not replaced by another. 
The scalp is left whitish, smooth, ivory-like, depressed, thinned, and 
apparently atrophied, without trace of the new-formed downy hairs 
often noticed in alopecia areata. As distinguished from the last-named 
disorder, the advance of the patch may be in irregular lines rather 
than by extension of the rounded or oval circles formed in alopecia 
areata. Minute islets of alopecia exhibit the outlying evidences of 
disease. 

(d) Cicatricial alopecias with a punctiform appearance of the plaque. 
Here there is an inflammatory involvement of the follicle and peri¬ 
follicular tissue, with redness of this special region that disappears 
after atrophy has occurred. The sequel is a depressed whitish cicatri- 
form tissue, marked here and there with pin-head-sized, reddish points 
where the circumpilary exudation is still in activity. 

(e) Quinquaud’s Disease 1 (Acn6 Decalvante, of Pailler and Robert). 
Here miliary abscesses, punctiform, pin-head-sized and larger, involve 
the follicle. The hair, originally piercing these suppurative lesions, 
is loosened and falls, after which the follicle atrophies and the hair is 
no longer produced. The scalp is left dead-white, thinned, depressed, 
atrophied, and cicatriform, in patches as large as those visible in alo¬ 
pecia areata, but often irregular in outline. The follicles remain dis¬ 
tinct and are not fused into a mass; they resemble the distribution of 
the lesions in coccogenous sycosis. In some instances this special 
follicular alopecia and scarring have progressed without suppurative 
involvement of the follicle, and in cases without any signs of inflam¬ 
mation. 

(/) Lupoid sycosis (Brocq); Ulerythema sycosiforme (Unna). Spe¬ 
cial attention should be directed to this affection, as it is of great 
importance to distinguish it from the more common variety of cocco¬ 
genous sycosis, which it strongly resembles. 

This disease chiefly affects the male beard (a region more accessible 
than the scalp to the fingers), and its early symptoms are well-nigh 


i Bullet, de la Soc. Med. des Hopit., 1888. 


510 


DISEASES OF THE SKIN. 


indistinguishable from those of sycosis of the type named above. 
There are large and small, well-defined, follicular and perifollicular 
pustules, with redness, infiltration of the derma, scales, crusts, and 
characteristic deformity. But as the disease progresses the hairs are 
removed from the whole or a large part of the involved area, and 
there is left, after a relatively long period, occasionally suddenly 
produced, a cicatricial or keloid-like surface, which may be smooth 
or highly irregular. 

In mild cases there is left a reticulum of narrow, scar-like, whitish 
lines, irregularly radiating over the surface, giving to the eye and touch 
the suggestion that they are depressed below the general level of equally 
irregular areas of the bearded chin or cheek. These areas may or may 
not be provided with hairs; iu the former event the growth is stunted 
by the contracture of the encircling atrophy, where a species of fibrosis 
has occurred. 

In severer cases there is left a more generalized cicatriform tissue, 
for the most part unprovided with hairy filaments. The process may 
be so severe as to interfere, not seriously, but to a degree with the 
movements of the lips in articulation and mastication. These parts, 
for months after the disease has accomplished its evolution, are still 
somewhat reddened. In both forms the centrifugal direction of the 
morbid process has been observed. 

( g ) In a last group are placed a few ill-defined cicatricial alopecias, 
beginning often with perifollicular, rather than follicular, pustulation, 
accompanied by redness of the affected part and the eventual formation 
of peculiarly persistent crusts. When these crusts fall a reddish, 
slightly scaly surface is left, followed by cicatricial atrophy and a patch 
with distorted and friable or fairly vigorous hairs, surrounded by an 
elevated rim. There is little definition; distinct patches of the disease 
are rarely seen. It more often affects the beard, and may be symmet¬ 
rical. It may coexist in the same subject with acne-keloid, atrophic 
acne, and other varieties of that disorder, with which it is unquestion¬ 
ably related. 

It will be seen from the foregoing that there has been recognized a 
series of interesting and important affections of the hairy parts, as yet 
not distinctly differentiated each from the other and the series from all 
others. Some of them may eventually be found to be varieties of 
lupus erythematosus; others, of tuberculous infection of the scalp. 
Kaposi’s dermatitis papillaris capillitii is without question to be recog¬ 
nized in some of the descriptions given. A few may be rare localized 
gummatous changes produced by syphilis. All are best treated with 
corrosive-sublimate lotions, one part of sublimate to four hundred; 
boric-acid lotions and powders; and salves containing mercury, sul¬ 
phur, and iodin. Galvano-cauterization of the pustules and inflam¬ 
matory points has successfully been employed in some of the reported 
cases. All these disorders are well managed if treated in accordance 
with the principles suggested in the chapter on Sycosis. 


ATROPHIES. 


511 


Keloid-Acne. 

(Acn£ K&LOIDIENNE, DERMATITIS PAPILLARIS CaPILLITII, 

Pi an Ruboide (of Alibert).) 

Under this title Kaposi describes a disorder characterized by pin- 
head-sized, isolated or confluent elevations of the skin-surface, with 
interspersed pustules, which finally form cicatriform plaques over 
which the hairs are either clustered in tufts or are totally absent. The 
pilary filaments are atrophied yet firmly fixed in their follicles, and 
they suffer elongation or fracture before withdrawal. The disease is 
encountered chiefly upon the nucha, the occiput, and the vertex. 
Papillomatous vegetations, crust-covered, hemorrhagic, and with a foul¬ 
smelling secretion, sometimes form, and eventually retract into a scle¬ 
rotic tissue. 

The author has described typical cases of this disorder, 1 each of 
which concluded with the production of a keloid-like, cicatriform, 
irregularly shaped, but circumscribed elevation of the surface. This 
feature is that by which it specially differs from all other sycosiform 
disorders. The disease seems to be due fully as much to inflam¬ 
matory processes in the subcutaneous tissue between the unyielding 
pericranium and the thick scalp as in the derma proper, and therefore 
it is not, strictly speaking, a dermatitis. Puncture, for example, of 
one of the pin-head-sized pustules, commonly gives exit to the usual 
quantity of pus; but pressure upon the scalp in the periphery will at 
once be followed by the appearance of a still larger quantity of similar 
pus, which evidently is expressed from a circumscribed subcutaneous 
abscess. When by such pressure the abscess-cavity is emptied, it 
slowly fills with venous blood, and produces a firm, semisolid eleva¬ 
tion of the surface that subsequently undergoes sclerosis, and the 
starved hairs above behave in the manner well described by Kaposi. 
The papules and plaques are formed in a similar way, by the abun¬ 
dant supply of venous blood. The case of one of the patients pre¬ 
sented at the clinic had been erroneously diagnosticated by a sur¬ 
geon as aneurysmal in character. Puncture of all such semisolid, 
cicatriform lesions is invariably followed by oozing of venous blood in 
abundance. The disease is chronic in character, is particularly liable 
to relapse in crops of pilary or peripilary pustules and papules, and it 
extends from nucha to vertex, curiously avoiding the frontal and tem¬ 
poral regions. Over the bald or partially bald keloid-like elevations 
there is seen, in some cases, a species of seborrhea in the form of more 
or less adherent, fatty crusts, with occasional characteristic tufts of 
hairs. 

The disease seems to owe its special character to the anatomical 
peculiarities of its location. It occurs preferably at the points where 
the venous supply of the scalp is not only greatest, but where it is also 
in most direct connection with the large vessels beneath, and where an 

1 Journal of Cutaneous and Venereal Diseases, vol. i. No. 2, p. 33. 


512 


DISEASES OF THE SKIN. 


inflammatory process in the derma or subcutaneous tissues invites with 
readiness a pathological afflux of blood. Such a focus, limited beneath 
by the dense calvarium, and above with the relatively thick scalp, 
readily undergoes organization and sclerosis, the subsequent behavior 
of the hairs and hair-follicles being an accident of the process. 

According to Besnier and Doyon, the disorder is only a papilloma¬ 
tous development, likely to occur in this region of the scalp as a sequel 
of epilating, cicatricial (keloid) acne, eczema, or traumatism. 

Sangster (in a paper read before the International Medical Congress 
in London, 1881) described a pigeon’s-egg-sized tumor of the scalp, 
that Kaposi, who was present, recognized as a case of dermatitis 
papillaris capillitii. 

Treatment. The method of treatment to be employed in this rare 
disease can scarcely be described as established. The affected surfaces 
are first freed from subcutaneous abscesses by puncture and expres¬ 
sion of the contents. Then the patch is washed with hot carbolized 
water, dusted with boric acid or iodoform, and a compress, moistened 
with an antiseptic solution, such as corrosive-sublimate wash, is rather 
firmly bandaged over the part. When pathological fluids no longer 
form under the scalp the patch is best epilated, and anointed with 
a salve containing 1 drachm (4.) of precipitated sulphur to the ounce 
(32.) of scented vaselin, which salve may also be kept constantly over 
the part. When crusts form they may be removed by shampooing 
with green soap. 

Generally, internal treatment is suggested by the constitutional con¬ 
dition of the patient, and it should often include cod-liver oil, the 
ferruginous tonics, and a roborant regimen. 


Ulerythema Aphryogenes. 

This affection was first described by Taenzer in Unna’s clinic. 
According to Unna, it occurs most frequently in blondes, is usually 
located in the eyebrows, from which it may spread to adjacent parts, 
including the scalp, or it may appear on the extensor surfaces of the 
upper arms. The condition may be no more than a persistent ery¬ 
thema, with small, elevated, horny papules at the mouths of the hair- 
follicles. The hairs are finer than normal and usually are broken off 
close to the surface. The disease may persist for years without further 
change, but in the severer forms atrophy, both follicular and interfol- 
licular, results, so that small, depressed scars are surrounded by, or 
commingled with, the hyperemic areas. The resulting alopecia is per¬ 
manent and may be very marked, especially on the eyebrows. 


ATROPHIA PILORUM PROPRIA. 

Atrophy of the hair may be either symptomatic or idiopathic. Illus¬ 
trations of the first-named condition are observed in phthisis, syphilis, 
seborrhea, ringworm of the scalp, and almost all general diseases inter- 


ATROPHIES. 


513 


fering with the nutrition of the pilary growth. The filaments then 
become dry, lustreless, friable in both longitudinal and transverse 
diameters, and diminished in each dimension. 

There are several recognized forms of idiopathic atrophy of the hair. 
One of these forms exists in those long hairs which are seen to be irreg¬ 
ularly thinned or flattened in the shaft, and split at the point into two 
or more recurving fibrillse, a condition noted, for the most part, in few 
hairs scattered among those of full development and vigor. This 
especially localized atrophy seems to be peculiar to one or more follicles 
merely; and is quite analogous to the condition in which there appears 
among the vigorous pigmented hairs of early life a single blanched 
filament. 


Fragilitas Crinium. 

Under this title a number of odd disorders, due to atrophy, and pro¬ 
ducing fragility, splitting, or curling in abnormal directions of pilary 
filaments, has been described by authors. 

“Undescribed form of atrophy of the hair of the beard,” 
of Duhring. 1 In this affection, either at the bulb or at a variable 
distance from it, but within the follicle, there is fission of the hair- 
filament into from two to four stalks with coincident atrophy of the 
bulb itself, and consequent irritation of the surface. Duhring’s patient 
exhibited to a marked degree the species of hypochondriasis to which 
the subjects of disease of the hair seem specially prone. Through 
the kindness of Dr. Duhring, the author had the opportunity of 
examining under the microscope some specimens of these hairs, the 
appearances of which are admirably portrayed in the woodcut which 
illustrates his paper. This disorder is not induced by a parasite. 

In 1887 a gentleman applied for advice who was in a fair condi¬ 
tion of general health, but the hairs of whose beard, when closely 
examined both with the naked eye and the microscope, presented a 
striking resemblance to those described and figured by Duhring. 
Photo-micrographs of specimens of these hairs show clearly that in 
every case the fission of the filament extended completely to the base 
of the follicle and produced there local irritation. The hairs over 
several square inches of surface were thus uniformly affected, normal 
filaments being in such areas absent. The interfollicular spaces, how¬ 
ever, seemed to be abnormally widened, as though in these areas such 
normal hairs might have fallen in consequence of a species of alopecia. 
The peculiar appearance of the beard to the naked eye was striking. 
The disease was much more strongly marked on the chin than on the 
cheeks or the upper lip. The curling of some of the splinters was 
complete and characteristic. 

1 American Journal of the Medical Sciences, July, 1878. 


33 


514 


DISEASES OF THE SKIN . 


Trichorrhexis Nodosa. 


Fig. 60. 


(Trichoptilosis (of Devergie), Nodositas Crinium.) 

Trichorrhexis nodosa, first described by Wilks and Beigel, is a con¬ 
dition in which the hairs display nodose swellings along the shaft at 

irregular distances, the beard and 
moustache being most often af¬ 
fected, though rarely there is in¬ 
volvement also of the hairs of 
the scalp, the axillae, and the 
pubes. The hairs are brittle,, and 
fracture usually occurs through 
the node, leaving a broom-like 
mass of filaments projecting there, 
while the internodular portions 
of the shaft appear normal save 
for some enlargement of the me¬ 
dulla (Fig. 60). The fragility of 
the hair at the centre of the node 
seems to depend upon the tension 
and consequent fissure of the cor¬ 
tical layer, which is greatest at 
that point. The hair-bulbs are 
firmly adherent in their follicles. 
In a form of this disease quite 
common among the women of 
Constantinople Dr. Hodara dis¬ 
covered a bacillus with pure cul¬ 
tures of which he reproduced the 
disease in a woman’s hair. It is 
probable that the condition is 
always caused by a definite micro¬ 
organism. 

Treatment is not very satis¬ 
factory, as a rule. Sabouraud 
highly recommends daily appli¬ 
cations of the following : 

R •—Hydrarg. bichlorid., | q 2 o 

Acid, tartaric., gr. viij., 0.40 

Resorcin., gr. xv.-xxx., 1.00 to 2 00 
Alcohol., - ) 2 . .. rAAA .. 

Ether., f 3 1SS > aa 50 00 M. 

Shaving has been followed in 
some of Kaposi’s cases by good 
results; while Koeser 1 advocates 
the local employment of dilute 
Trichorrhexis nodosa. (After Schwimmer.) tincture of Cantharides. 



1 Annal de Derm, et de Syph., 1877-78, pp. 185 et seq. 














ATROPHIES. 


515 


Monilethrix (Ringelhaaren; Moniliform, Beaded Hairs; Pili 
Annulati; Aplasie Moniliforme Intermittente) is a somewhat rare 
condition first observed by Smith (as described below), and since by 
numbers of others, including Luce, Anderson, Crocker, Lesser, and 
Behrend. A patient affected with this disease was exhibited at the 
International Congress of Dermatology, held in London in 1896. 
Like the forms of fragility described above, the hairs are peculiar 
in exhibiting along the shaft a succession of rings or nodes, between 
which are narrower portions of the shaft, of a color lighter than 
that of the pigmented nodular or annular portions. The result is a 
characteristic checkered appearance in the hairs. Fracture always 
occurs in the internodular part, the fractured extremity having a char¬ 
acteristic brush-like appearance. These conditions are evidently due 
to atrophic changes in the internodular parts, with better development 
in the pigmented and thicker portions of the shaft, the whole being 
due to nutritional changes in the hair-papilla. Virchow explains this 
condition as due to a periodic aplasia of the hair-papilla. The obvious 
symptoms are clearly the result of a profound process, originating 
probably in the trophic nerves. 

Nodose Swellings of the shafts of the hairs. Smith, 1 of Dublin, 
first reported a case of this disorder. Through the kindness of Dr. 
Duhring, the author was enabled to examine some of the hairs from 
this patient, photo-micrographs of which exhibit no fragility at the 
nodes, which beginning near the scalp were quite regularly displayed 
along the shaft, the fracture being always internodular. The spher¬ 
ical swellings along the shaft are also pigmented in a brown hue, and 
these pigmented nodose swellings contrasting with the non-pigmented 
color of the unaffected portions of the shaft, give the hairs a singularly 
“ checkered” appearance. No parasite was discernible in any of the 
specimens. 

Michelson, under the title “ Expansions and Fissures of the Hairs,” 
discusses together these and other abnormalities of the pilary system, 
and he concludes as to the most of them, that they are not separate 
diseases, but are expressions of an abnormal dryness and brittleness of 
the hairs due to atrophy. Cases of broom-like Assuring and division 
of the shaft into larger longitudinal splinters, he regards as equivalent 
processes, both beginning by a cuticular loss and often merging into 
each other. 

This view may be sound with regard to a number of these rare affec¬ 
tions; but even a superficial examination of the longitudinal splinters 
shown in Duhring’s and the author’s cases reveals the fact that the 
shaft represented by the sum of all its splinters is greater than that 
of the average hair in diameter and circumference. Even the naked 
eye can recognize this fact. The distention of the epilating-forceps in 
seizing a single hair, in the case of the author’s patient, was equivalent 
to the grasping of as many sound filaments as are represented by 
splinters. 


1 British Medical Journal, May 1,1880, 


516 


DISEASES OF THE SKIN. 


Treatment. The therapy of these cases is not well determined. 
Michelson believes shaving to be useless, and he recommends systematic 
shampooing and oiling. Arsenic internally is worth trying in all 
cases where it is not contraindicated. 


Concretions upon the Hair-shafts. 

Lepothrix. 

(Gr. tenog, scale; Opii;, hair.) 

(Trichomycosis Nodosa.) 

This disorder, first described in 1869 by Paxton, and since recog¬ 
nized by Patteson, Pick, Bab£s, Barthelemy, and others, is one affect¬ 
ing the hairs, chiefly of the axillae and the genital regions. The 
filaments are dry, brittle, roughened, and loosened in their follicles. 
Under the microscope the shaft is seen to be either for a great part or 
the entire length ensheathed in a concretion which may here and there 
be interrupted by furrows—a diffuse form of the affection. In a 
nodose form there are irregularly placed roundish masses, isolated from 
one another, and more numerous toward the point than near the im¬ 
planted extremity of the shaft. Crocker describes also circular and 
well-defined masses, lying upon but not surrounding the shaft, three 
times the diameter of the shaft, and containing fibres of the cortex 
that have been split away by the concretion. The fracture may be 
clean or be brush-shaped. The nodular masses are exceedingly well- 
attached to the shaft, and reddish-brown to blackish in shade. At 
times reddish sweat of the axillae, due to micrococci, has been a co¬ 
incident symptom. 

The nodes are found to be made up of chains of roundish or of 
elliptical micrococci, which penetrate the cortical layers of the hair 
with ease in regions of considerable moisture and sweat. The micro¬ 
organisms at first obtain access by minute separations of the cuticle of 
the hair, and they eventually penetrate more deeply, breaking up the 
cortical portions. While thus multiplying, a homogeneous substance, 
similar to the chitine by which the louse fastens its eggs to the hair, 
forms the bulk of the concretion in which the colonies of cocci are 
lodged. 

The treatment is by shaving and external applications of bichloride 
of mercury (1 : 2000). 


Piedra. 

Piedra is a term descriptive of blackish and exceedingly firm nodes, 
partially or completely surrounding the hairs, and distributed without 
special order along any part of the shaft. The nodes are of the size 
of that of a pin-head, and, though occurring chiefly in the hairs of the 
head of women, have been seen also on the scalp and the beard of men. 
Desenne, Morris, Juhel-Renoy, and Lion have reported on these cases. 


ATROPHIES. 


517 


The disease belongs to the group of hyphogenous disorders. The nodes 
are seen to consist of masses of spores with abundant mycelium, readily 
cultivated but never penetrating to the interior of the hair. The hair- 
bulb remains intact, and the disease is at once relieved by shaving or 
cutting the affected filaments. It occurs chiefly in Cauca, Colombia, 
but has been recognized elsewhere. In a single case, that of a young 
girl sent from the Chicago Eye and Ear Infirmary, there were numer¬ 
ous jet-black, horny, and dense spherical masses attached to the hairs 
of the eyelashes of each lid of both eyes. 


Beigel’s Disease. 

(Chignon Fungus.) 

This affection is discovered upon false hairs, which exhibit on their 
shafts dirty-brownish nodes, due to masses of parasites. The fungus 
has not definitely been distinguished. The nodes are irregularly 
strung along the shaft of the hair. 


Tinea Nodosa. 

This disorder, first discovered by Morris and Cheadle, affects the 
hairs of the beard or the moustache. The nodular concretions, which 
give the hair an irregular outline, are shown to be made up of fungus 
spores a little smaller than those of tinea trichophytina. The hairs 
are brittle and break or split. 

The treatment is by shaving or clipping, with the application of 
parasiticides. 


3. ATROPHIES OF NAIL. 

Atrophia Unguis. 

(Onychatrophie.) 

Atrophy of the nails may be a congenital or an acquired condition, 
in which there is deficient or defective production of nail-substance. 
The congenital forms are usually observed when the digits are poorly 
developed, and there is at the same time a deficiency of the pilary 
growth. The nails may entirely be absent in these cases, or merely 
be tardy of evolution; occasionally they are seen, especially upon rudi¬ 
mentary or coalesced digits, in defective and distorted shapes. 

In acquired atrophy the nail may be changed either in color, bulk, 
elasticity, firmness, shape, or position. Thus, the nail may be ex¬ 
panded and thin, narrow and acuminate, friable, furrowed, laminated, 
ridged, or otherwise distorted. It may uniformly or partially be 
lustreless, or singularly striped, or even irregularly speckled. 


518 


DISEASES OF THE SKIN. 


These changes in various combinations result chiefly from trauma¬ 
tism, such injuries, for example, as are common to the toes in the boot 
or shoe, and to the fingers when actively employed in the trades. 
Excessive heat and cold and constant maceration in chemical solutions 
(as among photographers, dyers, and druggists) often operate injuri¬ 
ously upon the nail-tissue. All serious disturbances of systemic nutri¬ 
tion, as are incident to prolonged fevers, surgical accidents, tuberculosis, 
ataxic conditions, etc., interfere visibly with the nutrition and devel¬ 
opment of the nail. Syphilitic changes in the nail are commonly due 
to gummatous involvement of the matrix. Severe ulceration of the 
matrix is often followed by atrophic or other distorted conditions of 
the nail-substance. 

The treatment of these conditions is largely that of the disorders 
upon which they depend. The nails may often with advantage be 
scraped to a desired smoothness, well trimmed, shampooed vigorously 
with green soap, employing this also over the adjacent soft parts of 
the digit, soaked in unguents, and then protected by wax, leather 
stalls, etc., from injurious contacts. Arsenic internally is said to be 
useful in some affections of this kind. 

Achromia Unguium. 

(Albugo, “ White Spots,” Decolorization des Ongles.) 

This is a peculiar condition found in young and healthy subjects who 
exhibit a number of dead-white macules on one or several of the nails, 
usually of the fingers. Morison, of Baltimore, reported an interesting 
case to the American Dermatological Association, 1 illustrated with a 
portrait, in which linear striae, transverse to the long axis of the digit, 
appeared on the fingers. The author has since then observed three 
similar cases of the disease, one the subject of a portrait in oil, where 
this condition existed. In all the author’s patients, young people of 
each sex, the fingers of the two hands were capriciously selected for 
exhibition of the peculiarity. It has been supposed that the presence 
of air in the nail-substance is responsible for the appearance. The 
affection is probably a trophoneurosis due to nutritional changes in the 
nail-matrix. 


4. ATROPHIES OP CUTIS. 

Atrophia Cutis. 

(Gr. a, privitive, and rpo nutrition.) 

Atrophy of the skin is an idiopathic or a symptomatic, diffuse or partial, diminution 
of the mass of the integument, or its reduction in size after loss or degeneration 
of one or more of its histological elements. 

The skin and its appendages, in common with other organs of the 
body, may suffer from atrophy, either idiopathic or symptomatic in 


1 Viert. fur Derm. u. Syph., 1888, vol. xv. 


ATROPHIES. 


519 


character, and general or partial in extent. It may result from either 
quantitative or qualitative, retrogressive changes, losing thus its nor¬ 
mal dimensions, either from wasting of one or of all its normal ele¬ 
ments, or from degenerative changes in the latter, or from their com¬ 
plete and final disappearance. Naturally these changes may be simul¬ 
taneous. They are usually effected slowly, and the results are persistent. 
They are frequent concomitants of a long list of other pathological 
alterations; usually, however, they succeed the latter. Under the 
general title of atrophy of the skin several rare forms of the disease 
have been considered. 


Atrophia Senilis. 

This is the frequently recognized cutaneous degeneration peculiar to 
old age. The skin becomes colored in various shades of brown, either 
uniformly or in tolerably distinct maculations over the face, the dorsum 
of the hands, the genitalia and the anus, and the lower extremities. 
The skin is seamed with furrows and wrinkles, often in various de¬ 
grees, desquamates slightly, and, losing the cushion of fat upon which 
it rested in earlier life, is either readily raised from the subcutaneous 
structures, or depends from them in loose folds. Pea- to finger-nail¬ 
sized, verruciform, dirty-yellowish accumulations of epidermis become 
visible, often in numbers on the face and elsewhere, extending either 
as far as the deeper portions of the horny layer or to the rete. 

The cutaneous atrophy in such cases may be characterized by unusual 
dryness, with failure of reproduction of the elements of the skin after 
the loss by physiological waste. The epidermis and derma by their 
shrivelling, lose largely their characteristic interdigitations, while the 
elements of which they are composed are impoverished in protoplasm. 
Vessels, relatively numerous before, disappear; pigment multiples; the 
hairs are either produced as lanugo filaments, or fall as the papillae in 
the fundus of their sacs flatten; the root-sheaths encroach upon the 
follicle; while the sebaceous glands and coil-glands may either disap¬ 
pear, or dilate and become filled with an epidermic detritus. 

In other cases the skin elements undergo a true metamorphosis, 
fatty, lardaceous, amyloid, colloid, waxy, or vitreous. 


Partial Idiopathic Atrophy 

of the skin occurs always as a result of the stretching or tearing of 
the elastic fibres of the derma. The skin, thus deprived of its normal 
degree of tension, permits at the site of such accident the vascularity 
of the subjacent tissue to be visible to an unusual extent through the 
epidermis, and there results a characteristic dull-reddish or slightly 
purplish hue in the lines or areas where the change is wrought. In 
the region involved an atrophy of the skin and sometimes a disap¬ 
pearance in part of the vascular plexus result. 

The causes which induce the stretching, the tearing, or the other 
chauges in the elastic tissue are exceedingly numerous. Prominent 


520 


DISEASES OF THE SKIN. 


among them may be named : traumatism (the persistent marks some¬ 
times left on the skin, for example, by a lash with a whip, insufficient 
to wound the epidermis but capable of injuring the deeper elastic 
tissue), ascites, anasarca, distention of the body with tumors, preg¬ 
nancy in women, excessive deposit of fat, and lesions of such disorders 
as syphilis and lepra. 


Atrophia Maculosa et Striata. 

(Vergetures.) 

Partial idiopathic atrophy of the skin occurs most frequently in linear 
cicatriform striae or streaks (an inch or more in length) developed 
chiefly about the hips, buttocks, and upper portion of the thighs in 
both sexes of adult years. Less frequently these striae are observed 
upon the neck, the trunk, and the extremities. They are insidious 
of development, indelibly persistent, and appear as sensibly thinned, 
glistening, and often depressed lines or furrows, having a whitish hue, 
with an occasional blending of a very delicate purplish tint. They 
are usually multiple, and at times abundantly displayed, running in 
various curves, for the most part at angles with the long axis of the 
body. They occasion, as a rule, no subjective sensation. 

Much more rarely the atrophic areas occur in macular patches. 
The lesions are then fewer, more isolated, and are discovered more 
frequently upon the extremities, but also upon the trunk, varying in 
size from that of a coffee-bean to that of a chestnut. This form of 
atrophy often succeeds either an erythematous or a pigmented condi¬ 
tion, which very slowly changes until there is formed a dead-white, 
round or oval, often insensitive patch, resembling coarsely a vaccine 
cicatrix. Taylor 1 and Atkinson 2 have described some very interesting 
features in this process. The lesions often occur about the ankles 
of women with menstrual derangements, the largest spot frequently 
attaining the size of that of the transverse section of a hen’s egg. 
The patches are in various degrees insensitive, very slightly depressed, 
smooth, glistening, and scar-like, the condition being the sequel of 
brown to chocolate-tinted pigmentations, limited to the spaces which 
become afterward atrophic. Cantani 3 describes similar atrophic 
macules, where there had been a bluish-red color, evidently due to 
the development of minute vascular capillaries. The sensibility of 
the skin was unaltered. Under the microscope both the linear and 
macular lesions show separation of the fibrous fasciculi, effacement of 
the papillary layer of the corium, and diminution in the number of 
vessels and glandular appendages. In Taylor’s and other cases the 
macules were quite hairless; in Atkinson’s case the hairs were rela¬ 
tively few in number. 

F6r6 and Quemonne* have also described two singular cases of the 
disease observed in Charcot’s clinic. In one of these cases appeared 

1 Archives of Dermatology, 1867, vol. ii. No. 2. 2 Rich. and Louis. Med. Journ., Nov. 16,1877. 

3 II Morgani, May, 1881. 4 Le Progres Med., Oct. 29, 1881, p. 837. 


ATROPHIES. 


521 


minute, whitish, elongated cicatrices, about which there was a marked 
pigmentation of the skin. They were abundant in the lumbar region. 
In a second case brownish lines appeared over the breast of an un¬ 
married woman, that gradually grew paler while others appeared over 
the skin of the throat. Those lines which were recent had a brownish 
or a bluish-red color; others were of a dead-white hue; some appeared 
over the lumbar region and the upper part of the buttocks; but there 
was none over the belly, the groins, or the thighs. In both cases the 
regions attacked were those in which there was no suspicion that the 
vergetures resulted from overdistention of the skin. 

These lesions are to be distinguished from sequels of scleroderma, 
syphilis, and other diseases capable of leaving atrophic areas. A 
previous history of such pathological conditions would usually be 
needful; but in the cases where there is precedent telangiectasis, hyper¬ 
emia, or marked pigmentation of the spot, the diagnosis, as several 
authors suggest, is attended with some difficulty. 

Partial symptomatic atrophy of the skin, in its simplest form, results 
from the traumatic action of tumors (ovarian, uterine, mesenteric, etc.), 
by which the skin is distended. The well-known results of a first 
pregnancy conducted to full term are linear atrophies, at first of a 
violet tint, and later of a dead-whitish hue, that are indistinguishable, 
both clinically and pathologically, from idiopathic lesions of similar 
aspect. Partial symptomatic atrophy, with degeneration of the cuta¬ 
neous elements (fatty, lardaceous, waxy, etc.), is a sequel common to 
a long list of cutaneous affections. 


Diffuse Idiopathic Atrophy 

of the skin, usually of progressive type, has been described under 
different names by several authors, namely, General Idiopathic Cuta¬ 
neous Atrophy, Atrophia Cutis Universalis, Progressive Idiopathic 
Atrophy. In these cases the skin over large areas, such as that cover¬ 
ing an entire limb or the trunk, becomes thin, flaccid, dry, scaly, 
unprovided with fat, and brownish or dead-whitish in hue. Puncta, 
stride, and plaques, reddish-blue or reddish-brown, or even purplish 
in color, are to be seen marbling the surface and occasionally leaving 
after disappearance a decided pigmentation. The process slowly ad¬ 
vances over the regions affected. 

Bronson has published his observations of a very unusual and inter¬ 
esting case of this form of atrophy, with references to the principal 
cases so far reported. 1 


Glossy Skin. 

(Atrophodermia Neuriticum.) 

The u glossy fingers,” described by Sir James Paget, 2 Gull, Mitchell, 
and others, are tapering, smooth, hairless, unwrinkled, glossy, pink, 


1 Journal of Cutaneous and Genito-Urinary Diseases, January, 1895. 

2 Medical Times and Gazette, March 24,1864. 


522 


DISEASES OF THE SKIN. 


and ruddy or blotched as if with permanent chilblains. One or sev¬ 
eral fingers are affected. The condition is associated with neuralgia or 
nervous impairment indicated by abnormal sensations, as of heat or 
intense burning. There is usually, however, a precedent or subse¬ 
quent neuralgic pain, with incurvation of the nails and at times heap¬ 
ing up of epidermal masses beneath the free border of the nail. In 
consequence of retraction of the skin over the distal phalanges the 
terminal extremity of the digit appears thinned and drawn away from 
the nail-bed. 

The complications of this condition are changes in the sebaceous 
glands and the coil-glands, loss of hair about the phalanges, excoria¬ 
tions, and in severe cases ulceration. 

This condition may be associated with grave systemic conditions, 
such as lepra, or with gout and rheumatism. It is found also in those 
in whom for any reason the circulation is feeble and there has been 
exposure of the extremities to severe cold. It has likewise been noted 
as the result of centric and peripheral changes in the nervous system. 
In some cases the cause is recognized as a neuritis; in other cases it 
may more properly be classed with the tropho-neuroses of the skin. 
The relations of this and several symmetrical disorders of the hands 
and feet to the so-called “ perforating ulcer of the foot,” u asphyxia” 
of the extremities, “ symmetrical gangrene” of the extremities, and 
so-called tc dying of the fingers,” all manifestly tropho-neurotic affec¬ 
tions (see the chapter on this subject), have not yet satisfactorily been 
established. 

Blanching Atrophy of the Skin. Several instances of this 
peculiar degeneration of the integument have been observed. It is 
characterized by an unnatural whiteness or pallor of the skin-surface, 
with considerable tension and tenuity of the epidermis, usually limited 
to the extremities (the arms and palmar faces, and the thighs and legs 
and plantar faces); moderate exfoliation occurs, and the latter, in con¬ 
nection with the tension to which the skin is subjected, is responsible 
for more or less painful subjective sensations. The disorder is chronic 
in its course, and it may originate in infancy. 

This condition is occasionally illustrated by persons affected with a 
sensori-motor paralysis of one limb, when the muscles waste and the 
fat-cells persist, multiply, or wholly disappear. The skin of such 
limbs, wholly or in patches, becomes unnaturally soft and delicate, and 
undergoes a loss of pigment and hairs, at the same time that its bulk 
actually diminishes. The nails may participate in the process. In 
other cases of trophic disturbance the skin shrivels and assumes, 
instead of a whitish, a yellowish or yellowish-gray tinge. 


Multiple Benign Tumor-like New-growths of the Skin. 

Under this title Schweninger and Buzzi 1 describe and figure lesions 
occurring chiefly on the back, but also on the arms and the chiu of a 


1 Internat. Atlas of Rare Skin Diseases, 1890-’91, v. 


ATROPHIES. 


523 


married woman, twenty-nine years of age. These lesions were bean- 
to coin-sized, bluish-white, and slate-tinted formations, with delicate 
telangiectases over the surface of some. By pressure most of them 
could be forced into a shallow pit in the underlying tissue, the tumor 
returning like a ventral hernia after removal of the pressure. The larger 
seemed to spring from the smaller lesions, and, as they increased in 
age, became flatter, less white, harder, and less compressible. They 
produced no subjective sensations and in no way interfered with the 
general health of the patient. The vigorous treatment adopted seemed 
to have but little effect on the growths. 

Under the microscope sections of the excised skin showed that 
elastic fibres were in every instance wholly wanting from the affected 
portions, nor were there signs of remnants or of degeneration-products 
of these elements. It was assumed that there had been in each locality 
a retraction of the elastic tissue, and that the resulting disease was due 
to a disturbance of the static balance, the overgrowth developing until 
the equilibrium was established. A growth of new and young cells 
was visible about the adventitia of the vessels and most of the acces¬ 
sory organs of the skin. 


Kraurosis Vulvse. 

Breisky , 1 in Austria, and Heitzmann and Ohmann-Dumesnil, in 
America, have described a condition of the vulva in women, affecting 
particularly the labia minora, the preputium clitoridis, and the vesti- 
bulum, in which there occurs a peculiar shrinking, shrivelling, or atro¬ 
phic change. The labia minora in some cases wholly disappear, shallow 
furrows taking their place. The clitoris becomes hidden from view 
and may be represented by a minute depression in the membrane. The 
integument covering this fhinned or atrophied tissue is whitish, thick¬ 
ened, roughened, and dry, while the surrounding parts are glossy, 
reddish-gray, or pallid in hue. Of twelve well-marked cases of the 
disease, itching was present in but four. Women of all ages, from 
nineteen to fifty, suffer from the disorder, irrespective of coitus and 
pregnancy. 

The study of three well-marked instances of this disorder indicates 
that for the present further investigation must be made before the 
identity of the disease can be accepted or its nosological position be 
established. The life-history of some of the affected patients must 
be had in order to gain a complete knowledge of the morbid con¬ 
dition. In one patient the resemblance was very striking to certain 
indolent epitheliomata of the penis, where a remarkable shrinking may 
at times be produced in consequence of metamorphosis of tissue. 


1 Zeitschriflt. f. Heilkunde, Prag u. Leipzig, March, 1885. 


524 


DISEASES OF THE SKIN. 


CLASS VI. 

NEW-GROWTHS. 

1. NEW-GROWTHS OF CONNECTIVE TISSUE. 

Keloid. 

(Gr. a crab’s claw.) 

(Cheloid, Kelis, Cancroid. Ger., Knollenkrebs, 
Alibert’s Keloid.) 

Statistical frequency in America, 0.124. 

Keloid is a benign cutaneous neoplasm, occurring as one or more elevated, whitish 
and reddish, firm, and elastic nodules, plaques, ridges, or radiating striae; or as 
several of such forms in combination, resembling a hypertrophied cicatrix. 

The term keloid , first given to this disease by Alibert, should be 
restricted to it exclusively. The so-called “ keloid,” of Addison, is 
known to-day more properly as scleroderma. 

Authors have described two varieties of this disease: first, the 
“true,” “spontaneous,” or idiopathic form; second, the “false,” 
“ spurious,” or cicatricial form. 

The best accepted view of this question is that the condition to which 
this name is given is one and the same under all circumstances. Keloid 
may occur when there is no evidence of a preceding disease or injury, 
and in that case it has been termed true keloid, though the opinion is 
gaining ground that in these cases there has been an ignored cause of the 
disease. Lesions occurring without a determined cause, in the present 
state of knowledge, may be classed as instances of primary (or true) 
keloid. Where there has obviously been a preceding disease or an 
injury the keloid condition is consecutive or secondary to the other. 
There is no anatomico-pathological separation between the two. The 
strong probability exists that all cases of so-called “ spontaneous 
keloid ” are instances of development of the growth in regions of 
pressure, contusion, traction, or such slight traumatisms as the wounds 
inflicted by mosquitoes. 

Symptoms. The new-formations of this disease are dense, generally 
elastic nodules imbedded in the corium, or projecting above the level 
of the skin and firmly attached to it. They are usually very slow of 
evolution, and, having once attained their full development and 
assumed one of the several shapes which they affect, usually persist for 
a lifetime. These forms are globular or semiglobular, whitish or 
reddish nodules, buttons, or plaques, with roundish or ovoid outline; 
linear elevated striae, bands, ridges resembling cords, ribbons, or tapes, 
in' irregular outline and disposition; or combinations of two or more 
of these figures. A common form over the sternum, and in other situ- 


NEW-GROWTHS. 


525 


ations where the development of the growth in every direction is not 
impeded, is that of a larger central mass with two or more diminishing 
and declining prolongations bearing a remote resemblance to the body 
and claws of a crab. The lesions vary in size from that of a small 
pea to that of a large saucer, the largest including the outlying points 
of the limbs or radiating ridges. Over it the skin is reddish or whitish 
in color, smooth, hairless, and occasionally hyper-sensitive to pressure 
and heat. The growth at times is also the seat of spontaneous pain. 

The most frequent site of the disease is the anterior surface of the 
chest, but it is observed also upon the face, neck, ears, breast, hands, 
between the scapulae, and on the extremities (Fig. 61). Keloid is 


Fig. 61. 



Keloid. 


also seen upon the penis of the negro. It is far more common in 
the colored than in the white races. Though frequently multiple, 
there are rarely more than a score of these growths visible at one time 
upon the skin of one person. 

The variations of keloid are not toward extremes. The overlying 
integument at times may wholly be uncolored in the white races, and 
dead-whitish in color or even blackish among the negroes. At other 
times the surface is not merely pinkish or reddish, but is vividly red in 
hue. The color is evidently produced by vascularization of the super¬ 
ficial portions of the growth, new-formed vessels, commonly largest 
at the base of the tumors, ramifying freely over the surface. The 
subjective sensations aroused may be trifling or inappreciable; at other 



526 


BISEASES OF THE SKIN. 


times the growths are the seat of severe pain or of burning. The 
usual course of the disease is toward the production of tumors of a 
medium size, after which few changes are to be recognized. Involu¬ 
tion and complete disappearance are rare. These results, however, have 
been secured in a few cases. 

Cicatricial Keloid (scar-keloid, hypertrophic scar, hypertrophic 
cicatrix) resembles in its features the true keloid described above, and 
differs from it chiefly in the fact that the cicatricial form is ordinarily 
preceded by scar-formation, due either to disease or to injury. It 
thus follows the lesions of zoster, variola, and syphilis, as also traum¬ 
atisms of all sorts, including those made by surgical operations and 
accidents. The tumors, as a rule, spring directly from the scar-tissue, 
and after reaching a maximum of development do not surpass the 
limits of the original lesions; at times, however, the growths slowly 
develop, as in spontaneous keloid, at a distance from the original site 
of injury or disease. SGar-keloid is often found as a firm nodule in the 
lobe of each ear among women, after piercing the ear for the insertion 
of ear-rings; it is seen also, not rarely, as a result of burns, whether 
produced by application of caustic agents or of heat. 

Etiology. The origin of the disease is exceedingly obscure. Neither 
age, sex, nor previous disorder of the skin seems to have any bearing 
upon its productiou. It is seen in remarkably vigorous persons (more 
often decidedly in the negro race), but also in those who are weakly. 
The very youug and very old are more rarely affected. 

Pathology. No little confusion has occurred in cousequence of the 
attempt to distinguish between keloid and cicatrix. Epithelioma, sar¬ 
coma, fibroma, and other diseases have existed with or complicated 
keloid, and the anatomical features of the last-named disorder have 
thus been obscured. 

Though not yet demonstrated, it is probable that eventually some 
varieties of keloid will be recognized as examples of cutaneous tuber¬ 
culosis. The race in which its lesions are most often and most volum¬ 
inously displayed is exceedingly apt for tuberculous infection; and the 
frequent recurrence of the disease after surgical excision and the 
peculiar lupoid aspect of certain keloid lesious are strikiugly suggestive. 

According to Langerhans, Warren, Kaposi, and others, in all cases 
of true keloid the papillary layer of the corium and the interpapillary 
projections of the rete downward are intact, the new-formation being 
strictly limited to the middle and lower portions of the corium, where 
there are numerous whitish, tendinous fibres of connective tissue, dis¬ 
persed for the most part parallel with the surface of the rete. In 
cicatricial keloid these observers find a partial or complete absence of 
the papillae and interpapillary processes. Babes, Crocker, and others, 
on the contrary, find that the papillae and rete may be normal, mod¬ 
ified, or absent in either form. Lymph-vessels with proliferated endo¬ 
thelium, compressed by longitudinal growth of the fibres, pass in both 
vertical and horizontal plaues, for the most part remaining patu¬ 
lous. There are few spindle-cells and nucleated cells. Many of 


NEW-GROWTHS. 


527 


the blood-vascular channels are choked or are absent. The sebaceous 
glands and coil-glands, hair-follicles, and muscles are pushed to one 
side by the new-growth and are often atrophied. 

Diagnosis. The clinical distinction between keloid and cicatrix is 
of trifling importance. The situations of the lesions of the keloid, 
often over the sternum, the infrequency of multiple tumors, its claw¬ 
like prolongations, and yellowish-white, reddish, or grayish-white color, 
all point to the nature of the disease. 

Treatment. Removal of keloid by cauterization and excision is not 
to be practised, as the growth does not fail to reappear. Vidal success¬ 
fully employed multiple linear scarifications. Various stimulating 
applications may also be made with a view to promote resorption, such 
as the spirit of green soap, iodated glycerin, iodin in ointment and 
tincture, and mercurial, salicylated, and lead plasters. Where there 
is pain anodyne unguents may be employed topically, such as freshly 
prepared belladonna plaster, or ointments of belladonna, stramonium, 
and opium. By far the most elegant of these, and the one which also 
is capable of producing an alterative effect, is the oleate of mercury and 
morphin, manufactured by Squibb, of Brooklyn. 

Internally, quinin, strychnin, arsenic, and the iodid of potassium 
have been exibited with varying success. 

Prognosis. As regards the general condition of the patient the 
prognosis is favorable. Very rarely there is spontaneous resorption 
of the nodule or tumor. Generally the latter may be expected to 
persist, after full evolution is attained, for an indefinite period of time. 


Cicatrix. 

Cicatrix is a dense, smooth, whitish or reddish new-formation of the skin, occurring 
where there has been a loss of connective tissue following traumatism or tissue- 
degeneration. 

A cicatrix, as has already been shown, is a new-formation of the 
skin, replacing connective tissue which has been lost by traumatism, 
by ulceration, or by some other pathological process. Most cicatrices, 
as, for example, those following the ulcerations of syphilis, the opera¬ 
tions of the surgeon, or the dermatitis produced by a severe burn, are 
reparative in their effect. 

They vary greatly in shape, size, color, and other characteristics. 
They may be smooth, glossy, shining, scaling, dull-whitish in color, 
or pinkish from vascularization of the surface. They may be linear, 
fan-shaped, circular, corded, ridged, dotted, crateriform, or tumor-like. 
They may be raised above the skin, on a level with it, or depressed 
below it. They may be deeply attached to periosteum or to bone, 
or readily be movable over the panniculus adiposus. They are of 
deeper color when young, and increase in whiteness with age. They 
are unprovided, as a rule, with hairs, or with coil- or sebaceous glands. 

The most insignificant cicatrices are those resulting from clean, 
incised, and punctured wounds and lesions of similar grade. Here 
the wounded surface furnishes a connective tissue that seals up the 


528 


DISEASES OF THE SKIN. 


solution of the continuity. Healing is then said to be by “ first inten¬ 
tion, ” and is at an end, so far as regards the gross appearances, in 
from one to two days. 

Healing by “ second intention ” occurs after a long period, in solu¬ 
tions of continuity of greater extent, and in those of the same extent 
in aseptic conditions. Here also newly formed connective tissue con¬ 
cludes the successive transformations from epithelium and leucocytes to 
embryonal vessels, pus, plasma, and cicatrix. 

Certain peculiarities of cicatrices are seen in special disorders where 
they are produced. The circular, oval, reniform, horseshoe-shaped, 
S-shaped, and figure-of-eight-shaped scars, thin and flexible, are char¬ 
acteristic of syphilis. The cicatrices of variola, zona, and ecthyma 
are slightly different each from the other, though all are of small size 
and depressed. Those of tuberculosis and dermatitis calorica of severe 
grade are exceedingly irregular and often corded. 

Hypertrophy of cicatrices is the condition already described as 
keloid. Here there is a tumor-like development of the cicatrix, form¬ 
ing a ridge, button, knob, indurated fold, or puckered and irregularly 
circumscribed, whitish or reddish lesion. These lesions follow almost 
every traumatism and destructive process to which the integument is 
liable. 

A case of cicatrix undergoing involution has been described by Dyce 
Duckworth, in a man (aged fifty) who suffered from rheumatic fever 
on two occasions, ten years before the date of report. This patient 
had pericarditis, and was blistered over the precordia. Nine months 
afterward lines of cicatricial growth began to form in the scar left by 
the blister, and they rapidly extended; in two years’ time they were 
still enlarging; in seven years some subsidence was noticed, and, when 
exhibited ten years after their first formation, involution was markedly 
progressing. This case illustrates the frequent origin of scar-tissue, 
its common occurrence over the sternum, and the fact of the subsidence 
of the new-growth in the course of time. 1 

Clulton 2 reports a case of cicatrix following erasion of a lupous patch, 
an issue which may be regarded as the most fortunate for any case. 

Purdon 3 announces the same result following a psoriasis treated with 
green soap; and Taylor 4 reports the same as a rare result of syphilis. 

Keloid-like cicatrix of the cheeks following acne is far from uncom¬ 
mon. Its lesion is usually smoothed down in the process of time, 
after the disappearance of the sebaceous-gland disorder, until the 
deformity is greatly lessened, and often scarcely noticeable. 

Etiology. The formation of a cicatrix is always preceded by a trau¬ 
matism or a pathological loss of tissue, the remote causes of which 
have the widest possible variation. Hypertrophied cicatrix is always 
developed from a simple scar. It affects persons of all ages and both 
sexes, but with decided preference for the negro race. The traumatism 
may occur from piercing the ears for ear rings, from the operations of 
surgery, from leech-bites, from the deeper burns from fire, and from 
wounds inflicted by accident. It often follows cutting the hands with 


1 British Medical Journal, October 8,1881, p. 597. 

3 Journal of Cutaneous and Venereal Diseases, 1883, p. 203. 


2 Ibid , January 20,1883. 
4 Ibid., 1883, p. 308. 


NEW-GROWTHS. 


529 


glass; and has been caused by the spur of a cock. It is sufficiently 
common after the occurrence of acne indurata, but the letter is of all 
its forms the least persistent. In general, it may be concluded, how¬ 
ever, that it occurs chiefly in those whose skins have a special tendency 
to such development. 

Pathology. Histologically, scars are seen to be made up of connec¬ 
tive-tissue bundles which interlace in all directions with great irregu¬ 
larity. In young scars the fibres are finer and the tissue is vascular, 
but as the scar grows older the fibres usually become coarser, and the 
vessels disappear. The scar-tissue proper is covered by a very thin 
epidermis, and Heitzmann claims that shallow and irregular papillae 
are always present. Kaposi demonstrated a difference, rather of dis¬ 
position than of kind, between keloid, hypertrophied cicatrix, and 
“ cicatricial keloid.” In the first, the epidermis is described as intact, 
while the corium at one level exhibits whitish, thickened, and closely 
packed bundles of fibrinous elements, lying parallel with the long axis 
of the tumor and the surface of the skin, traversed here and there 
diagonally by similar bundles, all probably derived originally from the 
sheaths of the blood-vessels. In the second, the papillary layer of the 
corium has been destroyed by the process of which the cicatrix is a 
resultant, and the latter does not surpass its original limits by invad¬ 
ing the unaltered peripheral tissues. The connective-tissue bundles are 
here also much less closely aggregated. In the third, the two forms 
described above can be seen combined, the papillary layer being de¬ 
stroyed, and the peripheral parts invaded by the connective-tissue new- 
growth. 

Diagnosis. The distinction between hypertrophied cicatrix and 
keloid is one chiefly of degree and needless from a practical point of 
view. Following the piercing of the lobule of the ear for the insertion 
of ear-rings, the lesion is distinguishable by pinching the part between 
the fingers, when a globular, pea- to cherry-sized mass will be felt 
firmly embedded in the derma between the reflected folds of the integ¬ 
ument. Upon the face, after the occurrence of acne, keloid can be 
usually seen as a puckered ridge, often transverse in direction, occu¬ 
pying the region of the cheek. 

Treatment. The resources of modern surgery are to be trusted in 
the production of laudable cicatrices when all antiseptic precautions 
are observed. The treatment of pathological conditions likely to be 
followed by cicatrices is the treatment largely of the special disease in 
which such loss of tissue occurs, e. g., the ulcer left by a degenerating 
syphilitic gumma of the skin. 

The treatment of hypertrophied cicatrix is the treatment of keloid 
already given. 


34 


530 


DISEASES OF THE SKIN. 


FIBROMA. 

(L&t.fibra, a fibre.) 


(Fibroma Molluscum, Molluscum Pendulum.) 


Statistical frequency in America, 0.075. 

Fibromata are cutaneous or subcutaneous neoplastic tumors, projecting in different 
degrees from the surface, single or multiple, of several grades of density, distinctly 
circumscribed, covered either by a sound and attached, or rarely by an ulcerated 
integument, and varying in size from a small pea to a foetal head. 

Symptoms. Fibroma is a disease characterized usually by the occur¬ 
rence of numerous, roundish, softish, semisolid, or solid growths, vary¬ 
ing in size from that of a small pea to tumors of several pounds weight, 
though more rarely the neoplasm is single. They are often called 
molluscous fibromata, as the disease was termed at one time molluscum 
fibrosum. When quite small they are seated within or beneath the 
skin, where they can be distinguished as distinctly circumscribed nod¬ 
ules, buttons, or plaques often slightly projecting. When more fully 
developed they become sessile, pedunculated, or largely pendulous 
tumors, hanging from the part to which they are attached so as to 
resemble in shape a cherry, a nipple, a pear, or a sausage. They are 
commonly covered by an integument which is natural in color and sup¬ 
pleness, though the latter may be traversed by blood-vessels; sprinkled 
with comedones or patent orifices of sebaceous gland-ducts; thinned 
or thickened, or in a state of ulceration; the last named being usually 
the result of externally operating causes in tumors of large size. 
They are productive of no subjective sensation beyond the more or 
less uncomfortable tension produced by the weight of those attaining 
a great size. When multiple they may be seen in various degrees of 
development, covering in hundreds, and even thousands, the entire 
body, especially the scalp, face, trunk, genitals, and extremities. 
Upon the lids they may interfere with vision by the production of 
ptosis. To the touch they may be felt as softish, somewhat elastic, 
firm, or tabulated masses, though at times nothing but a double fold 
of skin can be perceived, or a cordlike contained body. 

They are often congenital. When closely set together upon the skin, 
and of small size and pendulous, the features of the disease are char¬ 
acteristic. 

Schwimmer distinguishes between these lesions, usually congenital 
(termed by him, soft fibroma), and the dense tumors of similar anatom¬ 
ical features (termed by him, firm, or hard, fibromas). The latter are 
circumscribed, deeply seated, very slow of development, and apt to 
induce changes in the tissues which surrouud them. They may 
undergo fatty degeneration, or ossification, or calcification. 

Dr. R. W. Taylor, of New York, 1 in an interesting paper on the 
mode of development and course of fibroma, and its relations to acro- 


1 Journal of Cutaneous and Genito-Urmary Diseases, Feb. 1887. 


PLATE VII 



Multiple Fibroma of the Back. 


[From a photograph of one of the author’s patients.j 








NEW-GROWTHS. 


531 


chordon and other cutaneous offshoots, describes the first appearance of 
the disease as a roundish spot over which the skin is uplifted. It is 
of a light-pinkish color. The tumor is soft and suggests to the touch 
a thinning of the derma beneath. By firm pressure over such lesions 
when they have in size attained about half an inch in diameter, they 
may be slowly pushed downward into the skin, and the sensation is 
produced to the touch of a foramen in the derma. Fusion between 


Fig. 62 



Multiple fibromata. (Gross.) 


Fig. 63. 



Large single fibroma. (From a photograph.) 


the new growth and the skin over it is of early occurrence. The 
roundish or oval form of the tumor depends upon the direction of the 
bundles of the subcutaneous tissue of the part invaded. 1 lie tumors 
may undergo involution, but this result is more common when the 
patient is under thirty years of age. Dermatolysis is produced by 
great activity of the growth of one, or fusion of several tumors, by 
which a flap of skin is formed. 





532 


DISEASES OF THE SKIN. 


The large tumors of the skin of the patient carefully studied by 
Taylor suggested, when handled, that they contained boiled vermicelli, 
or a number of thread-worms, and contrasted thus with the firm or 
semisolid lesions of older patients affected with fibroma. The soft 
and gelatinous quality of the neoplasm in earlier life is believed to be 
proportioned to the age of the subject, and this rapid development and 
succulency of structure are only conditions of imperfect involution, 
aud are not to be looked for in the firmer, more slowly growing fibro¬ 
mata of later years. 

When involution occurs after full maturity of the lesions has been 
attained the softish contents of the tumors are adherent to the cutis 
above, and the cutaneous atrophy is proportioned to the rapidity of 
development of the growth and the firmness of its structure. Then 
comes a purse-like pedunculation of the tumor, produced by encroach¬ 
ment of the skin upon its pedicle, rendering its invagination, suppos- 
ably possible before, afterward difficult or impossible. Then gradually 
the neoplasm loses its skin connection. Eveutually in many cases 
only fibrous cords are left, evidently attached to the connective tissue 
beneath, the skin-color paling as the vascular tension correspondingly 
diminishes. Soon the dermal foramen closes, and the involutive pro¬ 
cess is at an end. Then empty and wrinkled pouches or purses of 
integument are left, whose further shrinkage produces multiple warty 
or nipple-like elevations of tissue (under the microscope recognized as 
fibrous structures with epithelial envelope), much in color like the 
virgin nipple, or the scrotum of a boy. From four months to a year 
were requisite for the mature development of the tumors, and nearly 
as long a period for the completion of the process of involution. The 
dermatolytic flap was permanent. Dr. Taylor believes, as a result of 
his interesting study, that there is the closest possible relation between 
fibroma and the verrucous growths called acrochordon and ecphyma 
mollusciforme. 


Dermatolysis 

(Chalazodermia, Pachydermatocele, Fibroma Pendulum, 
Lax or Relaxed Skin) 

is a condition which, as appears in what precedes, may be produced 
by fibroma and follow the involution of its lesions. In other cases it 
is apparently spontaneous and diffuse, but then is probably the result 
of some preceding condition which has been unnoticed. The skin of 
patients thus affected is in a condition resembling that of the young of 
several of the larger among the lower animals (pups of large hounds, 
etc.), where enormous flaps of skin may be gathered up between the 
fingers and extended a foot or more from the underlying tissue. On re¬ 
leasing such folds the skin retracts to its former position. The skin in 
these cases is usually thickened, but it may be stretched to a consider¬ 
able tenuity, as in the case of a man lately exhibited in America who 
could cover his face with skin pulled up from the surface of the chest. 
The integument may be externally normal to the view, or pigmented. 


NEW-GROWTHS. 


533 


It may be the seat of molluscous tumors; and either insensitive, or 
normally sensitive, or the seat of painful sensations. Usually all the 
functions of the integument are preserved. 

The anomaly is always partial and limited to either the face (the 
lids), the neck, the chest, the belly, or the genital region. The disease 
may be congenital or acquired. 

Dermatolysis, as thus recognized, is to be distinguished from the 
laxity of skin apparent in the senile condition and after distention from 
the presence of tumors, pregnancy, etc. Usually, however, in the 
last-named group of cases, it is the subcutaneous tissues which are 
relaxed rather than to any unusual extent the skin itself (e. < 7 ., the 
mammary glands of women of advanced years, and the abdominal 
muscles after distention of the belly). 

Etiology of fibroma. The disease is peculiar to neither sex; and, 
though observed in adults, is commonly first developed in childhood. 
It cannot be claimed as peculiar to any race, though in America 
negroes have probably furnished the largest field for its observation. 
Hebra called attention to the low standard of physical and mental 
development of the subjects of the disease seen by him, a fact well 
illustrated in a case recently presented, the patient being an exceed¬ 
ingly myopic, poorly nourished white, male dwarf, whose body was 
literally covered with fibromata from the scalp to the feet. In view 
of this well-established clinical fact the hereditability of the disease, 
which is rendered probable by recorded observations, seems capable 
of explanation. It has been noted in three successive generations 
and in seven children in one family. The precise cause of the disease 
is unknown. It is, however, reasonable to conclude that it is due 
to a vice of local development under the influence of a constitutional 
predisposition. 

Pathology of fibroma. The simple, soft fibroma of the skin is seen 
under the microscope to be a variety of myxo-fibroma and originates in 
gelatinous connective-tissue elements, which undergo metamorphosis 
into bundles of fibres, the tumors always exhibiting more of the formed 
fibrous tissue in the outer, and the formative or protoplasmic material 
in the central parts of the mass. In young tumors the fibres are 
delicate and form a loose network containing many spindle-shaped cells. 
As the growth becomes older and harder the fibres become coarser and 
more closely united, forming compact fibrous tissue in which there are 
very few cells. The vascular supply of fibromata is usually slight. 
The fibrous bundles pass downward, and unite with those of the derma 
or subcutaneous tissue, forming thus a firm attachment for the pedicle 
of all pedunculated tumors. There is some question as to whether 
these growths originate in the deep interspaces of the corium or in the 
connective tissue about the hair-follicles or fat-globules. 

A very large number of fibromata are of the so-called (t mixed ” 
variety. Some spring from the nerve-sheaths, and actually contain 
nerve-filaments (neuro-fibroma); others from muscular, vascular, and 
glandular tissues, the compound tumor receiving in this way a part of its 
constituent elements; often warty growths form with participation of 


534 


DISEASES OF THE SKIN. 


epithelium in the connective tissue, constituting thus an epithelioma 
(so-called u papilloma ”). The large pendulous tumors of nevus lipo- 
matodes may be examples of mixed fibromata, the surface of which is 
composed of pigmented and hairy skin. 

Diagnosis of fibroma. The tumors of molluscum fibrosum are to.be 
distinguished clinically from multiple cutaneous sarcomata, by the vio¬ 
laceous or reddish color of the latter, the absence of pedunculation, the 
greater tendency to ulceration, and their evidently malignant character. 
From tubercles of lepra they are differentiated by the entire absence 
of constitutional impairment and their general development in far 
greater multiplicity. The tumors of molluscum epitheliale differ in 
their contents, their superficial lo<ation, and in the frequent presence 
of the dark punctum at their summits. 

Neuroma is usually painful; lipoma less frequently multiple and 
pedunculated, and more suggestive, when handled, of a “ pillowy ” 
sensation to the touch. Warty growths are readily distinguished by 
their verrucous summits; and the gummata of syphilis, by the con¬ 
comitant or prior symptoms of the existence of lues. 

Treatment of fibroma. The treatment of large single fibromata is sur¬ 
gical, involving the employment of knife, ligature, 6craseur, or galvano- 
or thermo-cauterization. Multiple lesions are often so numerous as to 
forbid such interference. When there is a distinct vice of develop¬ 
ment or inherited tendency to the disease little can be accomplished 
in the way of treatment. 

Prognosis of fibroma. Rarely, one or more of these lesions disappear 
by spontaneous involution. More commonly they persist after their 
evolution is completed. Marasmus, tuberculosis, and a fatal result 
may occur. One or several of the tumors may become sources of 
danger from the occurrence in them of an active inflammation with 
resulting degeneration and septicemic consequences. The disease, 
however, does not, in many cases, shorten life. In general, the 
prognosis of multiple fibromata may be regarded as unfavorable. 


Neuroma. 

(Gr. vevpov , nerve.) 

Neuroma is a disease characterized by the occurrence of single or multiple, pin-head 
to small nut-sized, usually painful cutaneous papules or tubercles, constituted of a 
new growth of connective tissue and non-medullated nerves 

Symptom*. But few cases of this rare disease are recorded. The 
description appended is a summary of the symptoms detailed in the 
reports of Duhring, 1 of Rump, 2 and of Kosinski. 3 

The patients were all men of middle life or advanced years, who 
exhibited upon the shoulders, arms, thighs, or buttocks, numerous 
disseminated and defined, pin-head- to hazel-nut-sized, roundish, or oval 
nodules or tubercles. They were either painful, or painless at the 

1 Case of Painful Neuroma of the Skin. Amer. Journ. of the Med. Sciences, October, 1873 ; also 
supplement to the same, with cuts, Amer. Journ. of the Med. Sciences, October, 1881. 

2 Arch, of Path. Anat., Bd. lxxx. Hft. 1. 

3 Centralblatt f. Cnirurg., 1874, No. 16. 


NEW-GROWTHS. 


535 


outset and painful later. In Rump’s case, which was a sample of the 
false neuroma of Virchow (fibroid tumor of the nerve), there was no 
pain throughout the course of the disease. 

The nodules were not arranged along the tracts of nerves; were 
immovable, dense, and elastic; were fixed in the corium and extended 
below it. They were purplish or pinkish in color; and the skin between 
them was unaltered, or like that enveloping the lesions, dry, uneven, 
and desquamative. The tubercles were both tender and painful, the 
pain being excruciating, paroxysmal, usually lasting in Duhring’s 
patient for an hour, and radiating. It was aggravated by temperature- 
changes, mental emotion, and movement. 


Fig. 64. 



Neuroma of the skin; external appearance. (Duhring.) 


Histologically these tumors are composed of a mixture of fine con¬ 
nective tissue with medullated and non-medullated nerve-fibres; and 
should properly be called neuro fibromata. Sections of the growth in 
Duhring’s case showed anatomically a connective-tissue stroma, inter¬ 
woven with fibres for the most part lying parallel with one another, 
each fibre composed of a finely granular central substance surrounded 
by a sheath containing numerous, elongated, oval, somewhat granular 
nuclei. There were also yellow elastic tissue, blood-vessels with thick¬ 
ened and nucleated walls, and about the latter the lymphoid, cell-like 
bodies. There was entire absence of unstriated muscular and fibrillar 
connective tissue. The specimen was certainly unique, representing 
the true amyelinic neuromata of Virchow. In Kosinski’s case non- 
medullated nerve-fibres and connective tissue were also discovered. In 



536 


DISEASES OF THE SKIN. 



both cases exsection of a portion of nerve (brachial plexus, of the one; 
and small sciatic, of the other) was followed by considerable diminution 
of pain and almost entire disappearance of the growths. Io Rump’s 
case, which, as stated above, represented the fibromated and so-called 
fibro-nucleated tumors of Virchow, the nodules were strung upon the 
same nerve, “like beads upon a rosary,” and were similarly displayed 
upon its branches. Spinal, cerebral, and sympathetic fibres were all 
involved. 

Fig. 65. 


Microscopic structure of neuroma. (Duhring.) 

Duhring, in commenting upon these interesting cases, calls attention 
to the distinction between these purely cutaneous lesions and the gener¬ 
ally solitary, movable, and “ painful subcutaneous tubercle.” 


Xanthoma. 

(Gr. S-avOdg, yellow.) 

(Xanthelasma, Vitiligoidea. Fr., Plaques jaunatres des 

Paupi^res.) 

Xanthoma is a cutaneous neoplasm, exhibited in one or several, isolated or grouped, 
occasionally symmetrical, flat or slightly elevated, yellowish macules, papules, or 
tubercles, which are most commonly situated upon the eyelids. 

This affection was first discovered by Rayer , 1 and its clinical divis¬ 
ions established by Addison and Gull. 

1 Traits prat, des Maladies de la Peau. Paris, 1830. 










NEW-GBO WTHS. 


537 


Symptoms. The lesions of Xanthoma occur in (a) plane forms; (6) 
papular and tubercular forms; (e) as tumors. These may be com¬ 
mingled in one person. 

Xanthoma Planum. The flat or plane forms of the disease appear 
as bean- to finger-nail-sized plaques, either quite flat or with slightly 
elevated borders, often constituted by an aggregation of millet-seed- 
sized lesions, and covered with an apparently normal integument. In 
color they vary from light- or chrome-yellow to a “ coffee and milk” 
shade; and in shape they may be punctiform, roundish, oval, elongated, 
or quite irregularly grouped. They are distinctly circumscribed, and 
when gathered between the thumb and finger do not produce a sensa¬ 
tion of the presence of a foreign material. The plaques, examined 
closely, are seen to be compounded of fine yellowish nodules, each pro¬ 
vided with a somewhat reddish central point. They are most often seen 
upon the eyelids near the inner canthus, where they may be symmet¬ 
rically disposed about the two orbits, first appearing on one side; 
but they may invade also the periorbicular region, as also, rarely, the 
cheeks, the nose, the ears, and the nucha. They are rarely productive 
of subjective sensation, being occasionally the seat of slight pruritus. 
This is the commoner form of the disease. 

Xanthoma Papulatum and Tuberculosum, exhibiting papular 
and tubercular lesions of the same affection, may coexist with the 
plane lesions described above, and scarcely differ from the latter save 
in a greater development. The lesions are whitish or yellowish papules, 
plaques, and tubercles, circumscribed in contour, millet-seed to nut¬ 
sized, and at times much larger, covered with an unaltered epidermis, 
and determinable by palpation as having greater consistence than the 
flat macules. They are less frequently seen upon the lids, but occur 
upon the scalp, cheeks, palmar and plantar surfaces, the genital sur¬ 
faces, the genital region, and about the joints of the digits. 

Tumors of Xanthoma (Xanthoma Tuberosum) are sessile or 
pedunculated, cutaneous or subcutaneous in attachment, nut-to hen’s- 
egg-sized, originating in one or another of the lesions named above, 
and are described by Cary 1 and Chambard. 2 

Xanthoma Multiplex is the form in which the lesions, usu¬ 
ally first manifested in the sites of election and in their simplest 
development, proceed to a gradual invasion of the trunk and extrem¬ 
ities. Occasionally the mucous surfaces of the mouth, of the respira¬ 
tory and gastro-intestinal tracts are involved, as also of the surfaces 
of the peritoneum, endocardium, and larger arteries. The genital 
region, palate, oesophagus, spleen, trachea, and cornea have all been 
recognized as seats of the disease. 

The conglomerate forms upon the skin constitute large plaques 
resembling tumors, compounded of lesions of xanthoma tuberosum. 
They are distinctly circumscribed, deeply embedded in the coriura, 
elevated to the extent of one-fourth of an inch above the general level 
of the integument, and irregularly furrowed or lobulated superficially. 


1 Ann. de Derm, et de Syph., 1880, p. 75. 

2 Archiv. de Phys. norm, et path.. Sept, and Dec. 1879. 


538 


DISEASES OF THE SKIN. 


An illustration of xanthoma occurring in full development and in rare 
situations, taken from a photograph of an interesting case, is presented 
in the plate appended. 

Other cases display unusual features of this disease. In one there 
are flattened ribbons, exhibiting xanthomatous changes in both palms, 
stretching at right-angles to the long axis of the hand; in a second 
and somewhat rare form of the disease, isolated xanthomatous papules 
are attached somewhat regularly to the edges of the lids of both eyes, 
upper and lower equally, while large pin-head sized and equally isolated 
yellowish masses are visible below the orbits on each cheek. 

In certain cases the disease is accompanied by a generalized coloration 
of the skin in a yellowish shade, which has been variously interpreted 
as a xanthomatous dyschromia and as a true icterus. The former is 
the more probable explanation of the fact, as in such cases the urine 
and viscera have been found normal. A woman presenting one of 
the extreme phases of this icteroid xanthomatous condition of the 
skin was shown at the International Congress of Dermatology in 
London in 1896. 

Korach 1 has described the interesting case of a woman twenty-five 
years old, suffering from chronic icterus produced by closure of the 
ductus choledochus. Beside the typical patches of xanthoma on the 
lids, the skin-surface was generally and similarly affected. Thus the 
extensor faces of the extremities, the palms of the hands, nates, and 
other parts were extensively covered with sago-grain- to pepper-corn¬ 
sized papules and tubercles of xanthoma, both flat and elevated. 

Occasionally the tubercles exhibit a fine vascularization; and when 
there is a coincident jaundice the skin between isolated lesions is also 
tinted with the color of the xanthoma nodules. The jaundice, so- 
called, is rather common in the multiplex forms; and even when not 
readily recognized, the skin, at first sight of normal tint, is seen to be 
somewhat deeply colored in a shade of reddish-yellow. The regions 
of greatest pressure, outside of the lids and cheeks, seem sites of prefer¬ 
ence, as, for example, over the elbows, knees, palms, and buttocks. 
The mucous and serous membranes may exhibit well-marked involve¬ 
ment (conjunctivse, tongue, inside of lips, and entire surface of mouth, 
palate, pharynx, larynx, trachea, bronchi, oesophagus, vagina, rectum, 
peritoneal covering of the viscera, and the sheaths of the teudons). 
As a rule, there is scarcely distinguishable subjective sensation, patients 
commonly applying for relief of the resulting facial disfigurement. 
Occasionally burning and pricking, and rarely even painful sensations 
are produced. The patient whose lesions were selected for illustration 
of this chapter subsequently had the tumors removed from his limbs 
in order to relieve himself of discomfort in his work. 

The course of most cases is toward a maximum of development, 
after which the process ceases. In a few instances, usually not palpe¬ 
bral, complete involution has spontaneously occurred. The variations 
noted in the color of the plane and elevated forms of xanthoma are 
from a light-yellow to a deep-brownish and even blackish hue. Cases 


1 Deutsch. med. Wochenschrift, No. 20, 1881. 


Plate Vin. 







































V 

























NEW-GROWTHS. 


539 


occurring in children and infants seem to exhibit nearly the same 
features as those seen in adults. 

Etiology. The causes of the disease are obscure. In a few cases 
the lesions are first observed in early childhood, though they are encoun¬ 
tered chiefly in middle and later life. Women are rather more often 
affected than men. 

The belief is growing that xanthoma is due to embryonic and local 
causes. Many instances are on record in which several members of 
a family were affected. Torok and T. C. Fox have each reported 
families in which members of three generations presented the disease. 
The mother of the patient exhibiting multiple lesions upon the elbows 
and knees, whose case was selected for illustration of these pages, pre¬ 
sented plane lesions of xanthoma near the inner canthi of the eyes. 
The recent studies of Torok 1 in this direction are interesting and in¬ 
structive. The association of xanthoma with disease of the liver, 
rheumatism, gout, ovarian disease, migraine, syphilis, carcinoma, 
hydatids, and other disorders cannot be denied for certain cases. In 
the majority no such association can be recognized; and careful post¬ 
mortem examination of patients affected with xanthoma and dead of 
intercurrent disease, has either demonstrated a normal condition of 
the liver or a disorder of it quite disconnected with xanthoma, such 
as stricture of the bile-ducts from cicatricial contraction. In some 
reported cases occurring in diabetic subjects, three women and one 
man, the eyelids were unaffected, and the partially xanthomatous 
lesions transitory in duration. (See Xanthoma Diabeticorum.) 

Multiple plane lesions of the lid in a middle-aged woman have suc¬ 
ceeded a dermatitis of that region, induced by accidental contact with 
a corrosive solution of mercury. 

Pathology. The anatomy of xanthoma has been investigated spe¬ 
cially by Chambard, Balzer, Touton, 2 Torok, 3 and others. The process 
seems to be a connective-tissue new-growth containing cells infiltrated 
with fat-granules. Aside from the new-formed connective tissue and 
endothelial cells, there are seen between the interlacing fibres the char¬ 
acteristic “ xanthoma bodies.” These are cells varying greatly in size, 
having a distinct membrane, granular or fibrillated protoplasm, and 
large round or oval vesicular nudei, which vary in number from one 
to a dozen or more. 

These “ xanthoma cells ” are grouped especially about and along the 
vessels, and form globular masses in the deeper parts of the corium, 
though they may extend almost to the rete. They are more or less 
infiltrated with fat-granules, and correspond closely in structure to the 
developing fat-cells of normal connective tissue, but, as Torok has 
shown, they never go on to the formation of a fully developed cell con¬ 
taining one large drop of fat, and Unna finds they do not respond to stain¬ 
ing and other tests as do the fat-containing cells found in other tissues. 
There are also seen in the growth a transitional series of bodies between 
the connective-tissue corpuscle and the characteristic “ xanthoma cell.” 

1 Ann. de Derm, et de Sypb., Nov. and Dec. 1893. 

2 Viert. f. Derm. u. Sypb., 1885, Hft. 1, p. 3, with reference to previous reports. 

8 Ann. de Derm, et de Syph., Nov. and Dec. 1893. 


540 


DISEASES OF THE SKIN. 


The epidermis is usually unchanged, though it, together with the 
papillary layer, may be slightly thinned, and there is frequently a 
deposit of a yellowish-brown pigment in the deeper layers of the rete. 
The growth is almost wholly confined to the deeper parts of the corium, 
though occasionally portions extend to the subcutaneous tissue and 
may surround the coil-glands and hair-follicles. The sebaceous glands 
may be few, but are unchanged and are not, as was formerly sup¬ 
posed, concerned in the process. There is often a deposit of pigment 
in the corium, both free and in the cells, but the characteristic color 
of xanthoma is undoubtedly due to the fat-granules. 

The icterus and hypertrophy of the liver which sometimes compli¬ 
cate xanthoma are probably secondary and caused by the presence of 
the growth in the liver or in the biliary passages. 

Unna suggests that there are two forms of xanthoma of the eyelid: 
the one described above, and one in which there are seen peculiarly 
formed giant cells. This second fofm he thinks may be infectious. 
He has, however, examined but one case of this type. He also takes 
the ground that xanthoma multiplex is a wholly distinct disease from 
xanthoma of the eyelids. His conclusions are loased on the examina¬ 
tion of two osmium preparations sent to him from a distance, one of 
them taken from a glycosuric patient. These inferences are not sup¬ 
ported either by clinical experience or by laboratory observation else¬ 
where. 

Chambard, Morris, Crocker, and a few others believe the primary 
process is an inflammation which is followed by a fatty degeneration 
of the cells. 1 

Baizer’s conclusions as to the parasitic nature of the disease have not 
been verified by more recent investigators. 

Diagnosis. Milia occasionally occur in groups in the form of oval 
plaques upon the lids, but are distinguishable from xanthoma by the 
possibility of expressing their contents. 

The diagnosis from all other lesions is readily made, when consid¬ 
eration is had of the peculiar yellowish or saflron-like hue of xanthoma, 
and the common situation, form, and general characteristics of its plane 
or nodular lesions. 

Treatment. Erasion and excision are the usual methods of remov¬ 
ing xanthomata. Care should be taken in such operations to avoid a 
consequent ectropion when the operation is performed upon the skin 
of the eyelids. The Paquelin knife is objectionable on account of the 
radiation of heat to the globe of the eye. With the tumor slipped 
through an aperture in a thin sheet of asbestos paper, such as is now 
found in the markets, this inconvenience might be avoided. 

The modern method, however, of treatment by electrolysis is prefer¬ 
able to others. Caustics also have been successfully employed. Besnier 
employs phosphorus internally, followed by turpentine, by which the 
course of the disease is said to have been relieved. Wilson, with the 
same end in view, employed nitro-muriatic acid, arsenic, bitters, and 
blue pill. 

1 A discussion of this question and a resume of literature are found in the British Journal of 
Dermatology, August, 1892. 


NEW-GROWTHS. 


541 


Prognosis. The lesions, when not removed, are liable to persist 
through life. Spontaneous involution is said to occur very rarely. 
The French authors who have given considerable attention to this 
subject are disposed to believe that some cases of xanthoma tuberosum, 
with permanent xanthochromia and involvement of the inner coats of 
the larger vessels, may prove serious. 


Xanthoma Diabeticorum. 

(Glycosuric Xanthoma .) 

This rare disorder has been well illustrated by three excellent por¬ 
traits showing the features of the disease in a case reported by Dr. 
Robinson, of New York. 1 Instances of the disease have been also 
recorded since the cases of Addison and Gull (1851), by Hillairet, 
Morris (who was the first to claim for it an independent position), 
Chambard, Hardaway, Barlow, Fox, Crocker, Cavafy, and others. 

Symptoms. The lesions are usually multiple and numerous, discrete 
or confluent, and not rarely grouped, pin-head- to pea-sized, firm, well- 
defined, conical or acuminate papules. At the apex may be recognized 
a yellowish centre with reddish areola, which may be temporarily made 
to disappear under pressure. The appearance when viewed at some 
distance is suggestive of a pustule. Subjective sensations of itching, 
pricking, etc., may be produced. The lesions are visible over the 
buttocks, loins, elbows, knees, and extensor faces of the limbs in 
general, the face (brows, nose), the scalp, about the ankles and over the 
mucous surface of the mouth, and the palms and soles. But one case 
has been reported as occurring on the eyelids. The eruptive lesions 
are apt to be of sudden occurrence. After remaining upon the surface 
for a few months or years they may wholly disappear without leaving 
a trace of their existence, or the eruptive elements may in part only 
disappear. 

Etiology. In seventeen out of twenty-one cases reported glycosuria 
has been recognized; and Johnston calls attention to the fact that in 
nearly every case the patient has been described as stout, florid, or 
obese. The majority of the patients have been male subjects, and 
usually in a condition of fair nutrition. 

Pathology. Histologically the disease does not differ essentially 
from the ordinary form of xanthoma, except that the inflammatory 
changes are more marked, there is less connective-tissue formation, and 
there are fewer of the xanthoma cells than in the common variety. 
The lesions, moreover, are usually found near the coil-glands and fol¬ 
licles. Some observers claim that in this form of xanthoma the 
“xanthoma cells” are really giant cells, and that the process is 
wholly different from that of the common form of the disease. 

Diagnosis. Those who would separate this form of xanthoma 
from all others base the difference between them upon the following 


1 International Atlas of Rare Skin Diseases, iv. 1890, ii. 


542 


DISEASES OF THE SKIN. 


points: in xanthoma of glycosuria the sudden evolution and involu¬ 
tion of the cutaneous lesions; the firmness and solidity of the latter as 
distinguished from the softness of the ordinary forms; and the inflam¬ 
matory character of the glycosuric as distinguished from the keratosic 
qualities of the other variety. In xanthoma diabeticorum the yellowish 
apex is not at first apparent, nor in all the lesions, and, when it exists, is 
due to epidermal changes and not to those occurring in the corium as in 
xanthoma. Other characteristic features of the xanthoma of diabetic 
subjects are the absence of striae and patches, the absence of jaundice 
and of eyelid lesions, the presence of marked subjective sensations, the 
grouping of the lesions about the hair-follicles (well marked in 
Robinson’s case), and the absence of diabetes mellitus in most of the 
palpebral cases on record. This side of the question is ably presented 
by Johnston in reporting a case and in giving a summary of the 
twenty other cases so far recorded. 1 

On the other hand, it is urged by Besnier and Doyon that the gly¬ 
cosuria is simply an irritating cause which explains the differing symp¬ 
toms of xanthoma in the two classes of patients. Surveying the 
literature of xanthoma they find patients without diabetic symptoms 
suffering from atrocious pruritus and most of the special features 
claimed as peculiar to diabetic xanthoma of glycosuria. A woman, 
however, in middle life, recognized as the subject of diabetes mellitus 
(not insipidus), examined with special care, exhibited merely the 
common form of symmetrical and plane eyelid lesions. 

In the present state of knowledge on this subject it is difficult to 
state just what are the relations—if any—between these two forms of 
xanthoma. 

The treatment of the disease, medicinal and dietetic, is largely that 
of glycosuria. Robinson’s patient recovered after the use of small 
doses of Fowler’s solution. Local treatment may be employed as 
indicated in any case. 

The prognosis is favorable, all cases eventually recovering. 


Colloid Metamorphosis of the Skin. 

(Colloid Milium [of Wagner], Colloidome Miliare [of 
Besnier], Hyaloma, Hyalom der Haut.) 

About half a dozen cases of this rare disorder have been reported. 
The lesions occur chiefly on the upper two-thirds of the face, especially 
on the forehead and about the orbits. They consist of pin-head- to 
millet-seed- or even split-pea-sized, sharply circumscribed, irregularly 
rounded, flat papules, lemon-yellow in color, having a peculiar glisten¬ 
ing, translucent appearance suggestive of vesicles. They project but 
slightly from the skin, and on puncture give exit to a soft gelatinous 
mass, at times accompanied by a droplet of blood. Some of them 
may be surrounded by very slight telangiectases. They develop slowly, 


Journal of Cutaneous and Genito-Urinary Diseases, October, 1895. 


NEW-GR0WTH8. 


543 


often in groups, the individual papules remaining distinct even when 
two or more of them unite. Frequently a papule becomes depressed 
in the centre; or becomes inflamed and covered with a crust which falls 
and leaves a shallow depression but not a true scar. 

Etiology. The cause of the disease is not known ; it occurs alike in 
men and in women. In most of the cases reported the individuals lived 
an outdoor life and were much exposed to the elements. 

Pathology. This has been studied by Balzer, Besnier, Reboul, and 
others. Wagner’s belief that the process begins in the sebaceous 
glands is now practically discarded. Colloid degeneration is found to 
affect the connective-tissue fibres and cells of the derma which may 
become involved over considerable areas. The changes are especially 
noticeable about the vessels and nerves and about the sebaceous glands. 
The glands themselves, and all the epithelial structures—except the 
endothelia of the vessels—escape. The attempt to prove this disease 
to be identical with multiple benign cystic epithelioma (hidradenoma), 
in which the epithelial cells play so important a part, has not succeeded. 

Diagnosis. The disease is apt to be confounded with xanthoma, 
hidrocystoma, adenoma sebaceum, and multiple benign cystic epithe¬ 
lioma (hidradenoma). From the last-named disease the diagnosis is 
often very difficult or even impossible without the aid of histological 
examination. 

Treatment. The nodules may be removed with a sharp curette or 
by electrolysis. 


Adenoma. 

(Gr. adr/v , a gland ) 

Adenoma is a new-growth constituted in part of the cells of the glands and of their 
investing connective tissue found in the skin. 

Adenoma of the Sebaceous Glands. 

(Adenomes Sebaces (of Balzer and Menetrier), Adenomes 
Sebaces Cancroidaux, Acn£ Cancroidale.) 

The several forms of adenoma of the sebaceous glands may be 
assigned to two categories, the benign and the malignant. 

Acquired Benign Growths are pin-head- to pea-sized, sessile, 
roundish, oval or acuminate bodies, occasionally presenting points of 
whitish appearance suggestive of milium. They are situated chiefly 
over the face (forehead, furrows beside the nares). They are always 
covered by an unchanged epithelium and in color present the hue of the 
normal skin. 

Congenital Benign Growths are represented by the verrucous 
and vascular nevi of Pringle and Darier. They increase slowly after 
birth and attain a notable development at about the period of puberty. 
They also are found about the regions of the face named above, includ¬ 
ing the chin and the mouth. The lesions are pin-head- to bean-sized, 
and differ from those above described chiefly in the color they present, 


544 


DISEASES OF THE SKIN. 


which varies from a yellowish-white to a deep brownish-red; often 
the surface is vascularized by the presence of minute capillaries. They 
are sometimes discrete, often confluent, and may be commingled with 
comedones, acne pustules, pigmented patches, and the lesions of facial 
seborrhea. In the majority of cases other defects of the skin, such as 
warts, nevi, small papillomata, and pigment-spots, are present, while 
many of the patients reported have been mentally deficient or epileptics. 

The two forms named above are benign lobulated tumors of the type 
of sebaceous adenoma; the last-named group being distinguished by 
delicate telangiectases over the surface, and a verrucous structure. 

Malignant forms of Sebaceous Adenomata occur when the skin 
is in the senile state. They begin with the symptoms of an irritable 
acne or seborrhea, greasy crusts being displayed here and there par¬ 
ticularly over the surface of the face; or comedones of unusual type; 
or papulo-pustules which do not observe the course of those seen in 
earlier years. Ulceration attacks the lesion which at first seemed 
benign, and the issue is the development of an epithelioma. 

Etiology. The cause of these growths is not known. The majority 
of them are congenital, and those also which develop later in life may 
be congenital in origin. Most of the cases reported have been in the 
poor and in those of defective mental development, but cases are also 
seen in the well-to-do and intelligent. 

Pathology. The histology of these bodies has been studied by 
Pringle, Darier, Balzer, Crocker, Pollitzer, and others. There is 
undoubtedly hyperplasia of the sebaceous glands, which are numer¬ 
ous and large. Beyond this observers do not agree, and further 
study of the subject is necessary. Pringle described an interpapillary 
hypertrophy, Balzer found small cysts in both sebaceous and sweat- 
glands, Crocker reported an increased development of the coil-glands 
and hair-follicles, in addition to hyperplasia of the sebaceous glands. 

Diagnosis. The history of the disease, which begins in early life 
and develops gradually; the persistence and permanency of the individ¬ 
ual lesions situated chiefly on the middle of the face and specially in 
the naso-labial folds; the frequent occurrence of telangiectases with the 
papules above described; and the absence of suppuration or ulceration 
will usually suffice for a diagnosis. In colloid milium the lesions are 
usually few in number, are situated chiefly on the frontal and orbital 
regions, have a peculiar yellowish, translucent appearance, and are not 
so much modified by telangiectases. In multiple benign cystic epithe¬ 
lioma the lesions occur on the forehead and also on the trunk. Both 
of the two last-named diseases, however, may so closely resemble ade¬ 
noma sebaceum as to render the differential diagnosis impossible with¬ 
out the aid of histological examination. 

Treatment. Neither internal remedies nor external applications have 
any influence upon the lesions. The treatment is, therefore, surgical 
and calls for the employment of the knife, the curette, or scarification, 
depending upon the size, number, and location of the lesions. In one 
case where the lesions were few in number Crocker successfully 
removed them by means of electrolysis. 


NEW-GROWTHS. 


545 


Adenoma of the Coil-glands. 

Although the majority of cases formerly described as adenoma of the 
coil-glands are now classed with multiple benign cystic epithelioma, a 
few well-authenticated examples of the disorder are reported. 1 Perry 2 
describes a case, illustrated by a chromo-lithograph, of a woman upon 
whose face and trunk millet-seed- to small pea-sized nodules were 
visible, lasting for nearly twenty years. Upon puncture a clear fluid 
could be expressed from each. On section the coils of the sweat- 
glands were found enormously increased in size, and there was pig¬ 
mentation of the gland-cells. 

The diagnosis of this rare disorder can be made only with the aid 
of the microscope. 

The treatment is surgical, by means of the knife, curette, cautery, or 
electrolysis. 


Multiple Benign Cystic Epithelioma. 

This disorder has been studied by a number of observers and given 
a variety of names as follows : Hydradenomes Eruptifs (Jacquet and 
Darier); Syringo-cystad£nome 'Torok); Adenoma of the Sweat glands 
(Perry); Cellulome Epitheliale Eruptif Kystique (Quinquaud); Guta- 
stiges Epithelioma, Verbunden mit kolloider Degeneration (Phillip- 
son); Cystad6nomes Epith^lieux Benins (Besnier); Epithelioma Ade- 
noides Cysticum (Brooke). The name here adopted is the one given 
to the disease by Fordyce, whose faithful presentation of the subject 
forms 3 the basis of the following description. 

The disease is most common on the face, neck, and upper extremi¬ 
ties, but may develop on any part of the body. It is characterized by 
the appearance of small, pearly, pale yellow or pinkish-colored tumors 
varying in size from a small pin’s head to that of a pea. Larger 
lesions are exceptional. The tumors are firmly embedded in the skin, 
and also project above the surface; they are round or oval, solid and 
painless to the touch, the larger ones being tense, lucent, and freely 
movable. Some of the tumors are translucent, suggesting vesicles; 
others resemble milia and may be the seat of fine telangiectases; in 
others there may be a central depression which in some of the larger 
lesions of White’s case produced an appearance closely resembling 
Hutchinson’s crateriform epitheliomata. The lesions are discrete, and 
are not grouped or arranged in any characteristic manner. 

In most cases the tumors are first noted at or before the age of 
puberty; they enlarge slowly, rarely exceeding the size of a pea, and 
do not ulcerate or undergo spontaneous involution. White, 4 however, 
reports a case in a woman of forty-five on whose face were small typical 
lesions of this disease, and also others in varying stages of develop¬ 
ment up to true epithelioma of rodent ulcer type. The diagnosis was 
confirmed by the histological examination of a number of the tumors 
of varying sizes. 

1 Fordyce gives an excellent summary of the subject in Morrow’s System, vol. iii. p. 618. 

2 Intern. Atlas of Rare Skin Diseases, 1890-’91. 3 Morrow’s System, vol. iii. p. 620. 

4 Journal of Cutaneous and Genito-Urinary Diseases, 1894, p. 477. 

35 


546 


DISEASES OF THE SKIN. 


The cause of the disease is not known. In Brooke’s and White’s 
cases a distinct hereditary history was obtained. 

Pathology. The views of different observers regarding the path¬ 
ology of this disease is largely indicated in the names given to it by 
each. The following description by Fordyce is now quite generally 
accepted. Microscopical examination shows the tumors to be “ made 
up of irregularly rounded, oval, and elongated masses and tracts of 
epithelial cells corresponding to those in the lowermost layer of the 
epidermis and the external root-sheath of the hair-follicle.. The 
epithelial masses may be distinct, or made up of intercommunicating 
bands and tracts, in some places resembling coil-ducts. Cell ‘ nests ’ 
are met with as in malignant epithelioma, enclosing horny, granular 
and colloid tissue. Colloid degeneration of individual cells is also 
encountered in the cell-masses. The connective tissue about the cell- 
collections is somewhat condensed, but is not the seat of any inflam¬ 
matory process.” It is probable that these epithelial growths originate 
in a downward growth and proliferation of the epidermis and external 
root-sheaths of the hair-follicle, and not from the coil glands, as was 
supposed by some observers. 

Two cases only of those so far reported have shown any tendency 
to become malignant. It is possible that in the two cases these 
changes were accidents or coincidents such as occasionally occur in 
connection with verruca and other benign growths, but the histological 
structure of the small tumors closely resembles that of true epithe¬ 
lioma, and, as White suggests, it is quite possible that they would all 
in course of time show a malignant tendency, as most of the cases 
observed so far have been in young subjects. 

Treatment. The treatment is wholly surgical, with knife or curette. 
Many of the tumors are readily expressed with slight pressure, after 
the skin over them has been incised. Electrolysis is suitable for the 
smaller growths. 

Lymphangioma Tuberosum Multiplex. These rare growths 
supposedly of lymphatic vessels in the skin have been noted by Hebra 
and Kaposi, Pospelow, 1 Van Harlingen, 2 and a few other writers. 
The lesions in these several cases were practically ideutical, from a clin¬ 
ical standpoint, with those of multiple benign cystic epithelioma 
described above. By many observers the two diseases are thought to 
be the same clinically and pathologically, but Kaposi and a few others 
maintain that they are quite distinct in origin and in structure, stating 
that their cases showed under the microscope roundish or oval spaces, 
recognizable as distended lymphatic vessels by the characteristic endo¬ 
thelium with which they were lined. Kaposi distinguishes these 
tubercles from all subcutaneous cavernous tumors constituted of new- 
formed dilated lymphatic vessels reaching toward the skin, by the 
limitation in the former of the neoplastic growth to the superior parts 
of the corium. 

1 Viertelj. f. Derm. u. Syph., 1879, Heft 4. 

2 Paper read before the American Dermatological Association, September, 1881. Philadelphia 
Medical Times, September 24,1881. 


NEW-GROWTHS. 


547 


LEUCOKERATOSIS BUCCALIS. 

(Leucoplasia, Psoriasis Linguje, Smokers’ Patches of the 
Mouth, Buccal Psoriasis, Ichthyosis Linguje, Leuco- 

PLAKIA BUCCALIS ) 

In the year 1868 Bazin described with tolerable accuracy the several 
conditions indicated by the names given above; and since that date 
the subject has been enriched by a literature contributed by Debove, 
Kaposi, Sigmund, Plumbe, Mauriac, Schwimmer, Ingals, and others. 
The title of these paragraphs is that given by Besnier and Doyon, as 
the least misleading and the most descriptive. 

The disease is manifested chiefly in the mouth, by the occurrence 
on the inner faces of the lips and cheeks, and on the dorsum and edges 
of the tongue, of dull-whitish, slate-colored, or silver-whitish points, 
disks, streaks, bands, ribbons, or patches of an irregular shape, either 
flattened or slightly elevated above the general level of the mucous 
surface. The disease may occur in isolated points or in pin-head-sized 
nodules, discrete or confluent, and in cases grouped, the grouping being 
often in linear arrangements, following the lines indicated by the 
streaks or the striae of similar composition. 

The sites of election of these lesions are: the inner face of the cheek 
in a line following that traced by the conjunction of the teeth of the 
upper and lower jaw when approximated; the gums above the upper 
canine teeth and lateral incisors ; the sulcus beside the upper and lower 
gums in the roof and floor of the mouth; the dorsum and edges of the 
tongue, where the arrangement is usually in lines along the longitu¬ 
dinal axis; and more rarely other parts. 

When closely examined these lesions are found to be made up of a 
hyperkeratinized epithelium, being covered by an adherent and more 
or less dense pellicle, removable only by artificial measures and closely 
applied to the inferior stratum of the mucosa. The lesions are rough 
to the touch, both of the finger of the physician and to the tongue of 
the subjects of the disease, but are, as a rule, not painful, though at 
times annoying by producing a certain degree of stiffness and immo¬ 
bility of the parts affected. At times the membrane in the vicinity 
is reddened and tender. 

These lesions are extremely chronic of evolution, requiring months 
and often years for their full development, and resisting in a remark¬ 
able way the action of topical medicaments. They may be removed 
without recurrence; or may recur after complete and radical ablation. 
If unmolested and not undergoing resolution (a termination somewhat 
doubtful of occurrence), they usually, by reason of increased density, 
crack or fissure at one or another point, the fissure extending to the 
derma and arousing a local inflammatory process with the production 
of pain and distress. The surface is then apt to exfoliate and ulcerate; 
beneath these, sclerotic tissue is formed, and epithelioma of the mouth 
may result. 

The proportion of the benign cases to those which result in epithelioma 


548 


DISEASES OF THE SKIN. 


is not determined. Every leucokeratosis, however, may prove the 
initial stage of an epithelioma of the mouth; and the treatment of the 
former is, therefore, a matter of no little consequence. 

The etiology of these cases is suggested by some of the names given 
above. The disorder occurs almost exclusively in the mouth of the 
male and usually after middle life. Unquestionably the irritation 
produced by tobacco, whether used by smoking or chewing, and the 
influence of carious teeth or those with sharp edges after fracture 
irritating the edge of the tongue, are all important. The resem¬ 
blance of these lesions to the mucous patches of syphilis is obvious; 
and it is believed that syphilis, when not actively efficient in the pro¬ 
duction of leucokeratosis buccalis, may be one of its indirect causes. 
It is, however, very important to note that all the symptoms here 
described occur in persons who have never suffered from syphilis; and 
such symptoms are in the latter class fully as intractable as in others. 

Pathology . It is not definitely known if the primary change is a 
pure hyperkeratinization of the epithelium, or an inflammatory process 
of the papillary layer. The horny layer is hypertrophied, the cells 
retaining their nuclei. In the derma there is always more or less 
inflammatory infiltration, and often the papillae are partially obliterated. 
Fordyce states that overgrowth and proliferation of the interpapillary 
processes are exceptional. Leloir insists that the epitheliomatous process 
always begins not at the level of the hyperkeratosis of the mucous 
membrane, but below the fissure or other lesion induced by the indur¬ 
ation of the plaque or streak, indicating, in other words, that the 
epitheliomatous change is rather an accident than an essential part of 
the process. 

The diagnosis is chiefly from syphilitic lesions of the mouth, which 
should be recognized, as a rule, by their softness and tendency to ulcer¬ 
ate, as well by their situation, which is far less distinctive than in the 
case of leucokeratosis of the mouth. A history of infection and of symp¬ 
toms of the disease in other regions of the body would usually indicate 
the nature of the process. 

The only malady likely to be confounded with leucokeratosis of the 
mouth is lichen planus; and it is important to note that some confu¬ 
sion exists on this point in several descriptions of the two diseases. 

In lichen planus of the inside of the lips, over the tongue, the pal¬ 
ate, and other parts, dents, smooth, or fissured plaques, rings, festoons, 
linear striae, or disks may be recognized covered by a silver-whitish 
pellicle. It is clear that the distinction between these and leucokera- 
tosic lesions is in a high degree obscure, and for the present the most 
that can be done is to search with special care for other symptoms of 
disease upon the cutaneous surfaces of the body pointing to either lichen 
planus or to syphilis. 

The treatment of leucokeratosis of the mouth is first by abstention 
from all local irritants (tobacco; highly spiced, heated, acetous, and 
iced articles of food and drink), by the care of the teeth, and by the 
employment of soothing sprays or lotions containing the chlorate of 
potash, boric acid, balsam of Peru, iodized phenol, myrrh, borolyptol 
or muriated iron. 


NEW-GROWTHS. 


549 


The nitrate of silver may be applied to any ulcerated or fissured 
points, in both solution and by sweeping the solid crayons over the 
surface. The French make use of the salicylates in the same way. 

Destruction or removal of the lesions may be secured by the employ¬ 
ment of caustics, chemical or galvano-cauteric; by erasion with the 
curette; or by surgical ablation. 

No method seems preferable to the use, when practicable, of the 
burr of the dental engine after injection of muriate of coca’in. Where 
the patches are not too dense and extensive this has generally been 
productive of good results. 

The prognosis is fairly favorable in the case of all subjects of the 
disease who consent to deny themselves absolutely the luxury of 
tobacco-usage in every form, and who can follow a prescribed hygienic 
and medicinal course. For all others there is danger of epithelioma, 
and that without exception of any case. 


2. NEW-GROWTHS OF MUSCULAR TISSUE. 

MYOMA. 

(Gr. fiv&v , muscle.) 

Cutaneous myomata are divided by Besnier , 1 who has given the 
subject special study, into two classes: simple myoma, or liomyoma; 
and dartoic myoma. 

Dartoic myoma is much more common than is the other form, and 
is of chief interest to the surgeon. It is usually single and occurs most 
frequently on the mammai, the labia majora, and the scrotum. The 
tumor develops slowly, finally attaining a size varying from that of a 
small nut to that of an orange, and may be sessile or pedunculated. 
In most cases reported pain has been slight or absent, though it was 
marked in a case reported by Virchow. Under the influence of 
cold and local irritation the tumor usually contracts or may show a 
slow vermicular motion. Some of these tumors are composed almost 
entirely of non-striped muscle-fibres, others are mixed with other 
tissues to form a Fibromyoma, an Angiomyoma (Myoma telan¬ 
giectodes), or a Lymph angiomyoma. 

Simple Myoma is rare, less than a dozen cases having been re¬ 
ported. Its lesions are usually multiple and occur most frequently on 
the upper extremities, affecting chiefly the extensor surfaces, but they 
may occur on other parts of the body. They begin as minute papules 
which develop slowly to the size of a small pea or a bean, occasionally 
becoming larger. They are firm and elastic to the touch, are usually 
limited to one or two regions of the body, where they appear in patches 
without definite arrangement or grouping, and are pinkish, reddish, or 
normal in color. In the beginning the growths are usually insensitive, 

i Ann. de Derm, et de Syph., 1880,'p. 25 ; and Besnier-Doyon translation of Kaposi, vol. ii. p. 346, 
with references to all reported cases. 


550 


DISEASES OF THE SKIN. 


but in most cases they sooner or later become painful on pressure and 
in some instances they are the seat of paroxysms of severe pain 
which occur spontaneously and at irregular intervals. Nearly all 
the cases reported have been in elderly people and in men. Some of 
the tumors may undergo involution, but usually they tend to gradually 
increase iu size and in number. Histological examination shows that 
they are limited to the derma proper, and are composed chiefly of un¬ 
striped muscle-fibre mixed with some elastic tissue, aud are frequently 
developed about the hair-follicle. They are probably derived from 
the erector pili muscles. 

In a case under observation, multiple pin-head- to large bean¬ 
sized congenital tumors were situated near the sterno-cleido-mastoid 
muscle of a girl nineteen years old. These were exquisitely sensitive 
to pressure, were capable of slight vermicular motion when irritated, 
and examination of the largest, after removal, disclosed smooth mus¬ 
cular fibres, and, in small proportion, terminal filaments of cutaneous 
nerves. 

The diagnosis in well-marked cases is not difficult, but in some 
instances the determination of the disease must depend upon a micro¬ 
scopical examination. Myomata have been mistaken for xanthoma 
tuberosum, for keloid, for lymphangioma tuberosum multiplex, and for 
neuro-fibroma. The last-named tumors are painful from the begin¬ 
ning, and usually develop in the course of a nerve. 

The only successful treatment is by excision. 


3. NEW-GROWTHS OF VESSELS. 

ANGIOMA. 

(Gr. ayyeiov, vessel.) 

Angioma is that pathological development which is constituted wholly or in part 
of dilated or new-formed blood- or lymph-vessels. 

Angiomata are naturally divided into those composed of blood¬ 
vessels and those formed of lymphatic vessels. The former are much 
more frequent and variable in character. 

Blood-vascular new-growths occur in three forms: nevus vasculosus, 
telangiectasis, and angioma cavernosum. 

Nevus Vasculosus. 

(Nevus Flammeus, Nevus Sanguineus. Ger ., Gefassmal.) 

This term is limited to those vascular anomalies of the skin which are 
either visible at birth or become developed in a brief period thereafter. 
They commonly occur as irregularly outlined or distinctly circum¬ 
scribed, smooth spots, patches, or maculations, varying in color from 
light-red to deep-violet and port-wine, and are either flat or very slightly 
elevated above the general level of the integument. From this type 


NEW-GROWTHS. 


551 


wide variations are noted, in the development of pea-sized papules 
or tubercles to tumors even of larger size; pulsating and aneurysmal 
in character; spongy or relatively firm; lading or more rarely persistent 
under pressure; superficial or deeply seated; venous or arterial in 
their connections; single or numerous; and in either case limited to a 
small area or involving a relatively large surface. They are of most 
common occurrence upon the head, but are seen also on the trunk and 
extremities. Often they are the sole lesions of the skin present in a 
single individual; in other rarer cases they complicate moles, warts, 
and lymphangiomata. 

The surface of these lesions is usually smooth, though it may be 
rugous. They are generally compressible, losing their habitual color 
when the blood is forcibly pressed out from the loose meshwork of 
vessels of which they are composed, and becoming turgid and deeply 
tinted when the blood is forcibly driven into their tissue, as those of 
the face in the act of sneezing. 

The course of these lesions varies with their essential character. Of 
the simpler varieties, the larger number increase somewhat iu extent 
and development till they have attained a maximum size, and then they 
either persist indefinitely or accomplish a species of involution after 
agglutination of the vascular walls, leaving a whitish, cicatriform, 
occasionally pigmented surface. Others extend indefinitely, involving 
the neighboring mucous surfaces, subcutaneous tissue, and deeper 
structures, forming vast tumors, destructive not only by their tendency 
to extension, but by their mechanical effect. Fortunately, these ex¬ 
treme developments are rare. Much more commonly vascular nevi 
furnish the forms known as “ port-wine mark” or “ claret-stain,” 
which awaken no subjective sensations, and are usually of clinical im¬ 
portance in consequence of the marked disfigurement which they oc¬ 
casion. 

Occasionally, especially in the case of infants but a few days old, 
phagedena or gangrene will suddenly occur in these patches without 
appreciable cause (probably in consequence of the occurrence of throm¬ 
bus), and the entire tumor will be removed, the line of demarcation 
of the destructive process being exactly limited to the border of the 
angiomatous tissue. The scar resulting is superficial, and becomes 
smoother in course of time. In this way may occur spontaneous cure 
of nevi of considerable size existing on the head and genitalia of 
infants. 


Telangiectasis. 

(Nevus Araneus, “ Spider Cancer.”) 

Telangiectases are acquired blood-vascular new-formations which 
appear at periods of life other than at birth or a few months later; 
and are, therefore, distinct from the congenital forms of the disease. 
They are commonly first observed in adult life, and occasionally mul¬ 
tiply with advancing years. They occur in diffuse and localized forms. 
Diffuse, generalized telangiectasis is exceedingly rare. Hillairet and 


552 


DISEASES OF THE SKIN. 


Vidal have each observed one such case in individuals of both sexes; 
the condition being apparently due to systemic disturbance. 

The localized forms are betrayed by the occurrence of flat or slightly 
elevated, pin-head- to pea-sized macules; diffuse patches; linear ramifi¬ 
cations of individual vessels; or contorted congeries of a plexus of the 
latter, all exhibiting the variations in color of nevi vasculosi, but 
usually of pinkish or violaceous hue. They are unaccompanied by 
subjective sensations, are evidently non-inflammatory in character, and 
are seen as simple or multiple lesions chiefly upon the face, but also 
upon the neck, the back of the hands, the thighs, and other parts of 
the body. They are not rarely observed in connection with other dis¬ 
eases. Thus they occur in the vicinity of the lesions of lupus erythem¬ 
atosus, scleroderma, acne rosacea, cicatrices, and about the contour 
or over the surface of many malignant tumors. They may, therefore, 
have either an idiopathic or symptomatic character. 

The term Rosacea, as distinguished from acne rosacea, is employed 
to designate that condition in which the skin, of the face particularly, 
exhibits a circumscribed or diffuse redness, due to dilatation of the 
capillaries, unassociated with acne or other sebaceous gland disorder. 
(The reader is advised to cousult in this connection the chapter on 
Acne Rosacea.) 

The conditions here described as nevus vasculosus and telangiectasis 
are displayed in forms which, apart from the question of congenital 
origin, offer the widest differences and the most bizarre combinations. 
The so called nevus flammeus, nevus araneus (spider cancer), nevus 
vinosus, “ mulberry-/ 7 “ strawberry-/ 7 and “ mother-marks 77 are all 
examples of these combinations. 

The lesions may be congenital. There is not sufficient proof that 
they are due to ante-natal maternal impressions. The influence of the 
nervous system in deciding the area of limitation of the congenital 
forms is exceedingly distinct, as, for example, the definition of a port- 
wine mark in the skin area supplied by one supraorbital nerve. 

Pathology. Billroth states that the new formation has its origin in 
the vascular network surrounding in basket-like forms the fat lobules, 
follicles, and glands of the skin. Embryonal, vascular growths spring 
from these, and as they multiply and develop are enforced by prolif¬ 
eration of fibrous, connective, and muscular tissue. The color depends 
largely upon the preponderance of arterial or of venous capillaries in 
the new formation. 

Diagnosis. The ordinary lesions of angioma are readily recognized 
by their color, size, shape, and obvious vascular constituents. Ander¬ 
son calls attention to the importance of differentiating encephalocele 
due to the failure of ossification of the ethmoid and frontal bones 
at the root of the nose. Operations upon such tumors supposed 
to be angiomatous in character have resulted fatally. Lobulation, 
great distention (when a child is crying), a superficial rather than deep 
and complete vascularization of the smooth and glossy skin of the 
tumor, and a double pulsation in it, all point to frontal encephalocele. 

Treatment. The treatment of all forms of angioma is described in 


NE W- GROW THS. 


553 


detail in the chapter on Angioma Cavernosum. The best method is 
decidedly that by electrolysis when it is practicable. Then may be 
named: excision; amputation; injection of pure carbolic acid, taunic 
acid, or perchloride of iron; ligation of vessels; vaccination; ligation 
of tumors producing strangulation; the actual cautery; the galvanic 
6craseur; the use of the seton; and the application of such caustics as 
the ethylate of sodium. Squire’s method of multiple puncture and 
scarification has at times failed to accomplish the desired end. 


Angioma Cavernosum. 

(Tumor Cavernosus.) 

Cavernous angioma is distinguished from the angiomatous lesions 
described above by the peculiarities of its formation. It consists of 
a dense framework of new-formed connective tissue, inclosing loculi 
or chambers of varying capacity, containing blood and communicating 
not only with each other but with the larger vessels in the vicinity. 
Whether these blood-spaces originate in the fibrous felt-work of the 
derma, which later establishes a vascular connection, or in the vessels 
themselves, or whether they are constituted by a mechanical dilatation 
of such vessels, in consequence of a new-formed connective tissue in 
the adventitia, has not been determined. According to Virchow, the 
lesions arise generally from coalescence and dilatation of vessels. 
Other causes are explained by the earlier formation of a contracted 
cicatricial tissue by which vascular distortion occurs. (Rindfleisch.) 

Cavernous angiomata are said to be rarely congenital, developing 
soon after birth, and to be both superficial, deep, circumscribed, and 
diffuse. Sometimes they originate from a nevus or superficial telan¬ 
giectasis. Often when fully formed they are distinctly encapsulated. 
The diagnosis is between cysts, fibromata, lipomata, and sarcomata. 
The rarity of this affection in dermatological practice may be ex¬ 
plained by the surgical features of many cases. In five years no 
instance of angioma cavernosum was reported in the statistical tables 
of the American Dermatological Association. 

Etiology and Pathology of the Angiomata. The causes of the 
several forms of angioma named above are obscure. The sympto¬ 
matic telangiectases are undoubtedly to be explained by obstruction to 
the circulation occasioned by the tumor or other lesion to which they 
are accessory. The foundation for the vulgar belief that maternal 
impressions are responsible for the so-called u mother’s marks” is very 
slight. The reputed resemblance of the latter to various flowers and 
fruits generally requires for its recognition a stretch of the imagina¬ 
tion. 

Anatomically, these lesions are recognized as due to dilatation and 
formation of venous and arterial capillaries in the superior portions of 
the derma, the vessels of the newly formed plexus freely communicat¬ 
ing with each other. Generally there is a simultaneous new formation 


554 


DISEASES OF THE SKIN. 


of connective tissue constituting the framework of the growth, which 
varies considerably in the different forms of the disease. Lobules con¬ 
stituted of coils of capillary vessels are often separated by it into dis¬ 
tinct masses. According to Heitzmann, the large spaces of angioma 
cavernosum imitate the structure of the corpora cavernosa of the penis, 
and are filled with venous blood, being separated from each other by 
a scanty fibrous connective tissue. 

Treatment. The treatment of this group of new-growths is, in 
general, limited to a series of local surgical procedures. These opera¬ 
tions all have in view either the destruction of the new-growth, or the 
artificial production of an inflammation, in order to obliterate, to an 
extent sufficient to interfere with the transmission of the blood- 
current, the lumen of the capillaries of which the neoplasm is com¬ 
posed. 

First among these methods is electrolysis. One or a set of several 
fine cambric needles, with their points at the same plane, are connected 
with the negative pole of an ordinary zinc and carbon battery of ten to 
twelve cells. The points of the needles are quickly passed into the 
tissues, and there held for a period of between ten to thirty seconds, 
according to the effect produced after completion of the circuit, with 
a current of from one to two milliamperes. The new growth is thus 
blanched in the vicinity of the needles, this effect disappearing in the 
course of a few moments. 

In about three weeks the curative result of the operation becomes 
apparent. According to Fox, 1 of New York, the objections are that 
the operation is sometimes painful and tedious, and may occasionally 
result in the production of suppuration, superficial sloughs, minute, 
keloid-like elevations, vascular nodules, depressed scars, or superficial 
ulcers. In scores of cases, however, there is no production of results 
worse than the original disfigurement. Usually the success is com¬ 
plete. 

The method of Sherwell 2 is by multiple puncture with a set of fine 
needles in a holder similar to that described above. These are dipped 
in a 25 to 50 per cent, solution of chromic acid, and then made to 
penetrate the part to be attacked. The bleeding is readily arrested 
by pressure, and then the patch is to be covered with several superim¬ 
posed layers of flexile .collodion. This procedure is of value in cir¬ 
cumscribed patches of superficial character and relatively limited area. 
By it one can succeed in removing port-wine marks with the result of 
producing a somewhat irregular cicatriform tissue much less disfigur¬ 
ing than the original blemish. 

Squire’s operation is done upon previously frozen patches by the aid 
of an instrument which destroys the vessels by making numerous 
crossed and closely spaced linear incisions, parallel to each other and 
in a plane obliquely directed to that of the integument. Here also 
bleeding is arrested by pressure, exerted before the circulation is 
restored. The operation has been, in hands other than his own, 
attended at times with unsatisfactory results. 

1 New York Medical Record, Feb. 18, 1882, p. 18S. 

2 Archiv. of Dermat., October, 1879. 


NEW-GROWTHS. 


555 


Sodium ethylate, a compound in which the radical ethyl in ethylic 
alcohol is united with sodium, is a caustic recommended by Richard¬ 
son 1 in the treatment of nevus. It is applied by means of a brass 
rod. A first application usually results in the formation of a dense 
crust under which the nevus contracts, and repeated applications are 
made at intervals of a few days till the desired result is obtained. 
The sodium ethylate should be pure, and the crusts should not be 
disturbed till they fall spontaneously. In one case there was a per¬ 
sistent redness of the resulting scar which was decidedly open to ob¬ 
jection. 

Other methods employed are the ligature when practicable; puncture 
with hot needles; topical application of caustics other than those 
named above, such as hydrate of potassium, nitric and carbolic acids, 
and corrosive sublimate, and total excision, the latter being practicable 
in relatively small growths. Larger growths can also be removed 
and the surface covered with skin grafts. The galvano-cautery and the 
thermo-cautery are both valuable in the destruction of capillaries. 
For telangiectasis and nevi no larger than a pea the Paquelin knife is 
an efficient resort. The old method of multiple vaccination about and 
upon the involved area is frequently followed by the best of results, 
and whether in consequence of the retraction of tissue under the influ¬ 
ence of the inflammation excited, or of the destructive results of the 
suppuration induced, or of an indefinite caustic effect, is not, as 
Kaposi suggests, quite clear. 

These results may be partly imitated by the induction of superficial 
pustulation and suppuration through the medium of tartar emetic and 
croton oil, methods which certainly should be considered clumsy in 
the light of recent successes obtained by more manageable expedients. 

Injections with carbolic acid and the perchloride of iron, though in 
a few cases followed by fatal results, are at times successful. 

Coombs 2 has lately modified somewhat the method most in vogue, 
by passing fine silver wires through nevous growths, and connecting 
the extremities with a Bunsen battery. When the wires are heated 
the circuit is broken, and the ends of the wire disconnected from the 
battery and united to each other, being left in situ and covered with 
lint and plaster. The current can then be passed repeatedly without 
reinsertion of the needles, and the latter need be withdrawn only when 
the cure is complete. 

The treatment of angioma cavernosum requires surgical interference. 

The prognosis in any case of angioma rests upon the method of 
treatment adopted for its removal. In the larger number of cases 
the lesions, having attained a maximum development, persist without 
further pathological change, constituting a deformity rather than a 
disease. Physiological alterations in the color of such lesions occur 
under the influence of changes in the circulation. 


1 Lancet, November 9,1878. 


2 London Lancet, 1881. 


556 


DISEASES OF THE SKIN. 


Angioma Serpiginosum. 

(Infective Angioma, Nevus Lupus.) 

Angioma serpiginosum is a disorder characterized by the appearance on the skin, of 
minute bright-reddish points, often grouped, highly vascularized, and usually 
arranged in annular patches which spread by extension from the periphery, while 
the centre remains unaffected 

This disorder has been described and figured by Hutchinson, 1 Jamie¬ 
son, Lassar, Joy, White, and others. It is one of the rarer affections 
of the integument. 

Symptoms. The elements of each group of lesions are bright-red¬ 
dish puncta, resembling grains of cayenne pepper, arranged in oval or 
circular rings, definitely outlined, and a centimetre or more in diam¬ 
eter. The “ infective satellites 99 of Hutchinson are outlying points 
or patches where the disease is spreading. This extension is usually 
at the outer border of one of the annular groups of lesions. The 
-color varies from a light- to a deep-reddish hue or purple; tints which 
are due to the vascularity of individual lesions. The color can at 
times be made to disappear on pressure. 

The parts chiefly affected are the shoulder, the leg, the elbow, the 
ear, the arm, the hand, aud the skin of the chest. The disease may 
occur in infancy or adult years. Its evolution is slow, and usually 
unproductive of subjective sensations. The tufts of dilated capillaries 
which constitute the reddish points are occasionally not grouped in a 
■circinate or other special arrangement, but simply irregularly distrib¬ 
uted over the affected surface. 

Etiology. The cause of the disease is unknown. In a case under 
observation the lesions developed as a sequence of a congenital nevus 
of the vulva in a female infant. Hutchinson has made a similar 
observation. The affection has been more often noted among male 
patients. One case is supposed to have originated in violent mus¬ 
cular exercise. 

Pathology. The disease, being at first but obscurely understood, 
was until recently supposed to be one of the several expressions of 
lupus and was for that reason assigned one of the names given above. 
Lately, however, careful examination of tissue removed from a case 
fully reported by White 2 has thrown more light upon the pathology 
of the affection. White’s case was in all points typical of the disease, 
and microscopical examinations of the tissue excised were made by 
Darier, Councilman, and Bowen, all of whom were in practical agree¬ 
ment that the disease was an angio-sarcoma. Darier describes it as 
4t sarcome angioplastique reticule.” The corium was found well filled 
with small-celled infiltrations, and these cells had an epithelioid nucleus. 
There was abundant proliferation of the endo- and perithelium and a 
new formation of vessels. 


1 Arch, of Surgery, vol. i. plate ix. 

2 Journal of Cutaneous and Venereal Diseases, 1894, p. 505. 


NEW-GROWTHS. 


557 


Diagnosis. The disease is to be recognized by its vascular puncta 
and by their special tendency to grouping and extension through a 
serpiginous process never seen in simple telangiectases, nor in common 
forms of nevus vascularis. 

The treatment is by surgical ablation or destructive cauterization. 


Lymphangioma. 

In the present state of our knowledge on this subject it is not always 
possible to draw sharp dividing-lines between lymphatic new-growths 
on the one side and simple lymphangiectasis on the other. It is prob¬ 
able that the two processes are often associated. 

Lymphangiectasis, uncomplicated by growth of new vessels, may 
occur in the superficial or deep lymphatics. When superficial it forms 
pin-head- to pea-sized, isolated or grouped vesicles which have the color 
of the normal skin, disappear temporarily under pressure, and do not 
break easily, but on rupture give exit to a continuous or intermittent 
flow of lymphatic fluid. Elliott 1 describes an interesting case of this 
kind in which the vesicles bordered old scar-tissue and were seemingly 
identical in character with the lesions of lymphangioma circumscrip¬ 
tum, but histological examination showed them to be formed by simple 
dilatation of the lymphatic capillaries, due probably to mechanical 
obstruction. 

Lymphangiectasis of the deeper vessels often produces no change 
visible on the skin and can then only be recognized by palpation, or it 
may be displayed in raised, irregular cords or in chains of nodules. 
Following injuries or inflammation it may be acute, but usually it is 
chronic, and occurs most frequently on the lower extremities and in 
parts in which the return circulation is in some way impeded. The 
skin may become the seat of soft nodules which may rupture and form 
lymphatic fistules; but more frequently the greatest changes occur in 
the deeper structures, resulting in elephantiasis, in phlegmon, or in 
lesions of periosteum and bones, the skin of the affected region being 
oedematous, infiltrated, ulcerating, or cicatricial. 

Simple Lymphangioma may occur upon any part of the body in 
the form of circumscribed, elastic tumors made up of enlarged lym¬ 
phatics which are the result partly of dilatation of previously existing 
vessels and partly of new formations. The skin over such tumors 
may be unchanged or it may be reddened and thickened. In more 
extensive cases there is hypertrophy of the surrounding tissues as in 
deep-seated lymphangiectasis. Many of the diffuse forms of lymphan¬ 
gioma constitute firm or lax tumors of such size as to be termed 
Elephantiasis Lymphangiectatica or Pachydermia Lymphangiectatica. 
These tumors often contain large lymph-filled sacs or lacunae, enveloped 
in hypertrophied muscular and connective tissue, and an oedematous 


1 Journal of Cutaneous and Genito-Urinary Diseases, 1894, p. 137. 


558 


DISEASES OF THE SKIN. 


integument. Some of the elepliantiasic deformities of this character 
are fully as enormous as the extreme distortions of elephantiasis 
proper. Upon the tongue the condition is called Macroglossia, and 
upon the lips Macrochilia. 

Lymphadenectasia is a name given by Virchow to tumors usually 
in the axillary or inguinal regions, where the lymphatic vessels in the 
lymphatic glands dilate or multiply so as to form large tumors. The 
lymph-scrotum due to the presence of the filaria sanguinis hominis is 
elsewhere described. 

Simple lymphangiomata may be congenital. Their cause is unknown. 
It is supposed that they are produced by toxic or other irritating influ¬ 
ences. They are often the seat of a recurrent, circumscribed inflam¬ 
mation of erysipelatous type. Anatomically the lesions are found to 
consist of greatly developed lymphatic vessels and spaces, lined with 
endothelium and enveloped in small-celled connective-tissue stroma. 
The treatment, of the larger lesions only, is surgical. 

Cystic Lymphangioma belongs to the domain of surgery. It 
occurs in the form of multilocular cysts, usually congenital in origin, 
and most frequently situated in the neck. 


Lymphangioma Circumscriptum. 

This is practically the only form of lymphangioma entitled to special 
consideration by the dermatologist. It has been variously termed 
Lymphangioma Caver nosum, Lymphangiectodes, Lymphangioma Cap- 
illare Varicosum, Angiome Cystique, Lupus Lymphaticus. It is a 
rare form of skin disease and is well illustrated by the case of Morris. 1 

Symptoms. The characteristic lesions are small, deep-seated vesicles 
generally described as resembling frog’s spawn. They are usually closely 
crowded together in irregularly shaped groups from eight to twenty 
millimetres in diameter with normal skin between them. These groups 
have no regular arrangement or distribution. There are sometimes a 
few scattered vesicles about or between the borders of the groups 
which may coalesce to form new patches. There are usually several 
of these groups, but they are confined, as a rule, to one small region 
of the body. The most common sites, according to Francis, who 
has collected reports of twenty-eight cases, are on the upper parts 
of the extremities. In a very large majority of the cases reported 
the lesions occurred on the left side of the body. 

The vesicles are deep-seated with thick walls, and vary in size from 
that of a pin-head to that of a small pea. The newer and scattered 
vesicles may be colorless or have a yellow or pinkish tinge, but the 
skin over the older lesions may hypertrophy and produce growths that 
are easily mistaken for warts and may even result in decided warty 
projections. Other lesions may be more or less covered with telangiec¬ 
tases and vascular dots or tufts which may be present to such an extent 


1 International Atlas of Rare Skin Diseases, 1889, No. 1. 


NEW-GR 0 WTHS. 


559 


as to obscure the primary vesicle-formation. When punctured the 
lesions give exit to clear, colorless fluid which may be at times tinged 
with blood, the result of hemorrhage into the vesicle. 

In some cases the lesions and skin about them become the seat of a 
recurrent inflammation of erysipelatous type, 1 such as not infrequently 
complicates other forms of lymphangioma. Probably, as a result of 
these attacks of inflammation there is often infiltration, thickening, and 
even true hypertrophy of the deeper layers of the skin, forming a sort 
of local elephantiasis. 

The disease in most cases reported has begun in early childhood and 
developed very slowly, often remaining stationary for years. In but 
one case has spontaneous involution been reported. 

Etiology. As the disease usually makes its appearance in infancy 
or early childhood, it is quite probable that its origin is to be found 
in some congenital defect. It has appeared a number of times in con¬ 
nection with nevi. It has followed surgical operations, bordering the 
scars produced by the operator; it is quite possible that such cases are 
simple lymphangieetases of the capillary vessels due to blocking of 
the larger channels by the scar-tissue. 

Pathology. The vesicles, or cysts, are found on section to be situ¬ 
ated in the upper part of the corium. These cysts are shown to have 
an endothelial lining and are undoubtedly dilated or newly formed 
lymph-capillaries. Immediately about the cysts and dilated lymphatics 
in an early complicated lesion Bowen found considerable infiltration of 
round cells, but no other changes in the corium, while the epidermis 
was slightly thinned. In older lesions there is hypertrophy of the 
epidermal iayers, and sometimes of the deeper parts of the corium. 
In other cases there is more or less dilatation and apparently new 
growth of the blood-capillaries. This change in the blood-vessels 
may be slight or so marked as to form the chief feature of the disease 
both clinically and pathologically. In consequence, confusing reports 
have been made by different observers regarding the structure and 
origin of these growths, many of which seem entitled to the name of 
hemato-lym phangioma. 

Treatment. The treatment is surgical. The growth may be removed 
by excision or with the cautery. Electrolysis has been of service in 
some cases and should be given further trial. In several instances 
recurrence of -the lesions after complete removal is reported. 2 


1 Cf. White’s report, Journal of Cutaneous and Genito-Urinary Diseases, 1894, p. 47; also Bowen’s 
article in Twentieth Century Practice, vol. v. p. 687. 

2 For a description of five interesting cases of lymphangioma, with reference to literature to 
date, see Justin Robert’s article in the British Journal of Dermatology, 1896, p. 309. 


560 


DISEASES OF THE SKIN. 


Angioma Pigmentosum et Atrophicum. 

(Xeroderma Pigmentosum, Atrophoderma Pigmentosum, Der¬ 
matosis Kaposi, Melanosis Lenticularis Progressiva, 
Liodermia cum Melanosi et Telangiectasia.) 

Nearly seventy-five cases of this disease have been recorded; and 
these by Kaposi, Glax, Crocker, Vidal, Pick, Neisser, Geber, Taylor, 
Duhring, White, and others. Tables have been compiled by Kaposi, 1 
Archambault, 2 and Lukasiewicz, 3 including seventy-three cases. The 
disease results ultimately in a diffuse idiopathic cutaneous atrophy, 
but this condition is preceded by a general hyperemia with vascular 
dilatation; the production of numerous, punctiform, bright red, pin- 
head- to pea-sized, flat, or raised telangiectases; and disseminated, 
brownish, and yellowish-brown macules, varying in extent, between 
which form superficial, whitish and glossy, atrophic depressions, like 
the cicatrices of variola. The melanosis is at times so uniform and 
diffuse as to suggest the dark tints of the Spanish skin, as in White’s 
case, with a dense spattering of a still darker hue and a blackish 
scrotum. The atrophic or leucodermic condition of the skin may 
coexist with the melanoderma, and present large well-defined areas 
totally devoid of pigment where the skin may have a pinkish tint. 
The ears may thus come to resemble tanned sheep-skin. White, in 
the case under his observation, could trace no transformation from a 
pigment-macule into a telangiectatic lesion. The skin soon becomes 
furrowed, contracted, and as dry as parchment; and thus is readily 
developed an eczema or a superficial degeneration, including ulceration. 
A species of furfuraceous desquamation also occurs in patches. The 
faces of most patients exhibit a peculiar checkered appearance, from 
the uniform dissemination over the skin of the pigmented macules. 
Ectropion, with ulcerative keratitis, epitheliomatous, sarco-carcinoma- 
tous, and angio-myxomatous growths complicated several of the cases 
reported; and in two, certainly, were the immediate causes of a fatal 
issue. Often, however, the general health seems, for long periods of 
time, to remain unimpaired, the subjective sensations being slight. 
Observers of these cases differ somewhat as to the order in which the 
several lesions of the disease appear; and Duhring thinks it possible 
that no definite order is observed in the evolution of the symptoms. 
Both sexes in early life seem equally predisposed to this disease, though 
the large number of members of single families affected with its 
symptoms indicates the importance of predisposition and heredity in 
point of etiology. It is usually manifested before the third year of 
life. 

The regions involved are, as a rule, the exposed surfaces, viz., the 
face, ears, neck, shoulders and chest to the third ribs and even to the 
lumbar region, the arms and back of the hands, occasionally the legs 
and the dorsum of the feet. The yellowish-brown, freckle-like spots 

1 Wiener med. Wochenschr., 1885. a Dermatose de Kaposi, Bordeau, 1890. 

3 Archiv. fiir Derm, und Syph., 1895, Band xxxiii. p. 37. 


NEW-GBOWTHS. 


561 


are soon after their appearance intermingled with superficial cicatri- 
form depressions, either unnaturally whitish in hue or of the color of 
the normal skin. The punctiform or linear dilatations of the vessels, 
usually numerous, furnish a striking contrast with the freckled and 
pigmented parts. In some parts the skin is seen to be of a parchment¬ 
like thinness; in others it is furrowed, laminated, and split, as if too 
dry or too brittle. It is usually deprived of its normal suppleness, 
is retracted, aud is often attached to the subdermic tissue. 

The disease commonly begins in the first or second year of life, and 
progresses continually. The order of occurrence of the lesions as 
given by Kaposi is the freckle-like pigmentations, surmounted in the 
course of a year or two by telangiectases; then a gradual disappearance 
of the latter and occurrence of the cicatriform depressions; finally a 
diffuse atrophy of the skin. New pigment-spots continue to form, so 
that a given case usually presents all types and grades of lesions. 

The eczemas of the face, superficial ulcerations, and ocular changes 
(pterygium; ciliary blepharitis; telangiectases of conjunctive) are all 
secondary to the general conditions described above. 

In the course of years verrucous growths appear, starting usually in 
the pigmented spots, either epitheliomatous, sarcomatous, or angio¬ 
matous in character. They may be single or many; may be confined 
to the skin or develop in the viscera; and usually lead to fatal results 
in a few or many years. 

Pathology. The disease probably begins as a proliferation of connec¬ 
tive tissue in the papillary layer, with involvement also of the vascular 
endothelium, followed in some points by retraction and in others by both 
ectasis and new formation of vessels. By Kaposi, who has the honor of 
first naming and describing the disease, the irregular accumulation of 
pigment is regarded as consecutive to the vascular changes. The rete- 
pegs extend deeply below; there is ectasis of the glands and epithelial 
degeneration. 

With the French the disease is generally regarded as a pigmentary 
epithelioma or “ epitheliomatous lentigo” (Quinquaud), the connection 
between the neoplasm and the pigment-anomaly being regarded as 
similar to that recognized in melanotic sarcoma. 

The etiology of the disorder is exceedingly obscure. A congenital 
predisposition is shown by the occurrence of several cases in one 
family; most of the patients have been females. There is a very 
singular disposition of the disease to select one sex in different families. 
In forty-three cases collated by Kaposi there were six times, two; four 
times, three; and once, seven brothers or sisters affected with the dis¬ 
ease. The age of the patients first exhibiting the disorder is from the 
first to the second year. Schwimmer has reported one case occurring 
in the thirty-fifth year. Unna believes it possible that the action of 
light upon the skin has an influence in the production of the disease. 

The diagnosis is chiefly from scleroderma, but as the latter always 
begins with induration of tissue, and as angioma pigmentosum et atro- 
pliicum always begins with either erythematous or pigmented spots, 
the distinction is clear. In a case of scleroderma, too, apart from its 
onset at a later period of life, the pigmentations are late rather than 

36 


562 


DISEASES OF THE SKIN. 


early; and the telangiectases are found in circumscribed scleroderma 
as a violet-tinted border about a patch; never as points, nodules, and 
stellate markings, interspersed among pigmented spots and depressions. 
Lepra maculosa is characterized by marked anesthesia in and about 
the pigmented and non-pigmented areas ; further, its course is toward 
mutilations of the body, and even at an early period there may be 
vesiculation. 

The treatment of the disease is limited to amelioration of the condi¬ 
tion of the skin by means of local applications varied to meet the indi¬ 
cations as they arise. Surgical ablation of tumors, with electrolysis 
of smaller lesions, may be employed to prevent or postpone a fatal 
termination. 

The prognosis is in the highest degree unfavorable, as most of the 
patients succumb to marasmus in from ten to twenty years. 


Rhinoscleroma. 

(Gr. pig, or piv, the nose, and cr Kkrjpog, hard.) 

Rhinoscleroma is an infectious granuloma affecting the skin and mucous membranes 
of the nose and other organs, characterized by the formation of exceedingly dense, 
elastic, and painful, flattened or elevated plaques, nodules, or tubercles, which may 
be isolated or confluent. 

Symptoms. A knowledge of this rare disease, first described by 
Hebra and Kaposi in 1870, has been obtained from a study of some 
one hundred cases observed by these and other authors. The follow¬ 
ing is a concise description of the malady as thus presented. 

The disease commonly begins in the septum or a single ala of the 
nose, without inflammatory symptoms. The involved parts slowly 
enlarge, and become finally as dense as ivory. The individual lesions 
are flat patches, or elevated and circumscribed nodules, papules, and 
tubercles, painful upon pressure, movable to a certain extent over 
underlying tissues, and covered either by a normal integument, or by 
a light- or dark-red, shining, vascular epidermis. Neither hairs nor 
glands are discernible over the lesions. As the disease progresses the 
alae become enlarged, flattened, and so indurated that they cannot be 
pressed together, while respiration may be impeded by stenosis of the 
nares. The process may extend to the neighboring parts, involving 
thus the upper and lower lips, gums, velum, epiglottis, larynx, trachea, 
and jaws, the teeth meanwhile falling from their sockets and the soft 
palate becoming in some cases perforated. Involution of the process 
has not been observed, and the lesions do not degenerate by ulceration. 
Max Zeissl, 1 however, reports a single case in which there had been 
ulcerative destruction of the entire left nostril, as well as of the tip 
and right ala of the nose. Occasionally superficial excoriations have 
occurred, but very rarely a diminution in the consistency of the mass. 
The disease is exceedingly chronic, requiring years for its development; 


1 Wien. med. Woch., 1880, p. 621. 


NEW-GRO WTHS. 


563 


and though the affected parts are painful on pressure, they are other¬ 
wise not the seat of subjective sensation. 

Etiology and Pathology. The disease is observed between the 
fifteenth and fortieth years in persons of all social conditions and in 
individuals of both sexes, free from syphilitic, strumous, tubercular, 
and other cachexia. 

Kaposi originally observed, as anatomical lesions of the disease, a 
dense infiltration of the corium and its papillary layers with small, 
closely packed elements, which he recognized as a true new-formation. 
He considered this as analogous to the small-celled sarcoma, inasmuch 
as Mikulicz, Geber, and Billroth have seen some of the elements of 
the neoplasm transformed into osseous formations sufficiently common 
in sarcomatous tumors. 

In 1882, however, A. v. Frisch, after examining tissue removed 
from lesions of rhinoscleroma in twelve patients, found in the cells 
and between them in the interpapillary fissures of the connective tissue 
bacteria distinctly rod-shaped, one and one-half times longer than they 
were broad. These germs were successfully cultivated, but experi¬ 
mental inoculations with culture-fluids thus obtained were negative in 
results. Dreschfield 1 found in sections of tissue obtained from Payne’s 
patient numerous bacilli less slender and smaller than those occurring 
in tuberculosis and with slightly thickened extremities. These were 
unlike those exhibited at the Berlin Congress by Paltauf, who con¬ 
siders them closely related to Friedlander’s pneumococcus. Barduzzi, 
Pellizari, Cornil, Alvarez, Lustgarten, and others have added to the 
evidence in favor of the parasitic nature of the disease. 

The bacilli are found encapsulated in a colloid-like substance and in 
series of twos and fours. They occur in the lymphatic ganglia, in the 
giant cells of the neoplasm, and in protoplasmic masses corresponding 
to these or to their degenerate nuclei. The process of phagocytosis 
has been determined after injections of cultures of bacilli obtained from 
the juice of rhinoscleroma. Pawlowsky, of Kieff, in 1890, in this way 
demonstrated that the bacilli of the disease are pathogenic for the lower 
animals. Besnier and Doyon, however, pointing to the limitation of 
the disease to Austria, reject a parasitic origin for the disease. Mibelli, 
who has given the subject careful study, found two kinds of cells 
characteristic of the process: one a dropsical and the other a colloid 
cell. He thinks these types are the result not of cell-degeneration, 
but of the presence of zooglea, a mucous substance produced by the 
bacilli. 

Diagnosis. The disease can hardly be mistaken for another in con¬ 
sequence of its situation, the disfigurement it occasions, the ivory-like 
elasticity and induration of the affected parts, and the rarity of ulcera¬ 
tive degeneration. As distinguished from syphilis, it is known to be 
entirely unaffected by specific medication. However, since rhinoscler¬ 
oma has been by some writers assumed to be a form of syphilis, it is 
needful to distinguish clearly between the two. But as in the former 
affection there is very rarely any softening of the ivory-like induration, 


1 British Medical Journal, October 24,1885. 


564 


DISEASES OF THE SKIN. 


much less ulceration, which is so common in syphilitic gummata, the 
distinction is tolerably clear. From the variety of acne rosacea of the 
nose known as rhinophyma rhinoscleroma is readily differentiated by 
the softness and compressibility of the acneiform affection and its evi¬ 
dent vascular and glandular composition. 

The ulcerations of epithelioma have a more circular outline, a more 
elevated edge, and occur in persons of a more advanced age. Keloid, 
if found in the situation of rhinoscleroma, does not ulcerate. 

Treatment. The method of relief thus far employed is a total or 
partial extirpation of the neoplasm. Kaposi speaks of dilatation of 
the nares, where there is actual or threatened nasal occlusion, by 
means of laminaria and compressed sponge. Both excision by the 
knife and destruction by caustics have been found to secure merely 
temporary benefit, as the growth is reproduced with some rapidity. 

Prognosis. The future of the patient is grave. The disease not 
only persists and recurs after operative interference, but may endanger 
life by obstruction of the nostrils. Zeissks case proved fatal in ten 
years after the disease first appeared. 


TUBERCULOSIS CUTIS. 

Cutaneous tuberculosis is declared in the occurrence of numerous and differing 
lesions, characterized by inflammatory, plastic, or retrogressive changes in the 
skin and subcutaneous tissues, due to infection by the bacillus of tuberculosis. 

Tuberculosis is one of the most common, formidable, and destruc¬ 
tive of the great scourges of the human family. It may attack either 
primarily or secondarily any organ or tissue of the body. The skin 
is not rarely the seat of its ravages, and when gravely involved the 
results are in the highest degree disfiguring aud repulsive. 

The consequences of tuberculous invasion of the skin are usually 
declared early in life, because in those periods the skin is most easily 
invaded, and also because at these ages the habits and environments of 
the individual are conducive to the occurrence of the accident. Tuber¬ 
culosis of the skin may be th« result of general infection in the body; 
or may, on the other hand, be the starting-point of such infection. In 
either event the disease is always originally acquired by infection and 
not by inheritance. Children are rarely, if ever, born tuberculous. 
The coincidence of several members of one family exhibiting evidences 
of the disease is most readily explicable by the opportunities for 
infective accidents furnished in such families. 

In the pages which follow no attempt is made to revert to the 
remarkable and instructive history of the gradual acquisitions of science 
on the subject of this disease. Neither within these limits is it desir¬ 
able to indicate the several conditions which in their relations to this 
subject have been confused in the past, and whose names have served 
as titles for chapters on cutaneous disorders. It will be sufficient if 
the results obtained from the vast and valuable labors of the patholo- 


NEW-GRO WTHS. 


565 


gists and clinicians of the last decade be concisely set forth with a 
view to the simplest systematic conception of the subject. 1 

Tuberculosis of the skin is conveniently studied in its several forms 
of (1) lupus vulgaris; (2) tuberculosis verrucosa; (3) tuberculosis cutis 
orificialis; (4) scrofuloderma. 


1. Lupus Vulgaris. 

(Lat. lupus, a wolf.) 

Statistical frequency in America, 0.433. 

Lupus vulgaris is a tuberculosis of the skin and mucous membranes manifested in 
the production of cutaneous lesions which by resorption, metamorphosis, or ulcer¬ 
ation, may be productive of grave local injury, and, in cases, be the point of origin 
of generalized tuberculosis. 

Symptoms. The symptoms of lupus vulgaris are both numerous and 
diverse, a fact which may account for the many names which have 
been applied to its different manifestations, and which with few excep¬ 
tions are descriptive merely of certain external features. 


Fig. 66. 



Lupus vulgaris of the face (from a photograph). 


The lupous infiltrate may be limited to small areas or diffused over 
an entire region of the body. It may be first apparent in pin-head- 
to bean-sized flattened maculations (Lupus Maculosus, Lupus 
Planus), from which may be later developed papules, tubercles, nod¬ 
ules of equal or somewhat greater size, rising above the general level 

i In the preparation of this chapter the author has derived valuable aid from a symposium on 
the subject prepared at the request of the Council of the American Dermatological Association, by 
Drs. James C. White, of Boston ; John T. Bowen, of Boston; and George Henry Fox, of New 
York. Boston, 1892. 



566 


DISEASES OF THE SKIN. 


of the skin and often perceptible within its mass by palpation. (Lupus 
Nodosus; Lupus Tuberculatus, Elevatus, Tumidus, Nox-exe- 

DEXS, NoX-ULCEROSUS.) 

It is to be noted that as in syphilis in the course of which, though 
almost every one of the elementary lesions of the skin may be devel¬ 
oped, there is a distinct predominance of the papule and tubercle, 
so in lupus vulgaris the type of the disorder is certainly shown in 
the lupous nodule, the “ lupoma,” as it is by some authors desig¬ 
nated. 

This dull-reddish, purplish-shaded lesion, scarcely as large as half 
a pea, may be the predominant symptom of a lupous patch for a 
period of from ten to twenty years and even more. It is of a softish, 
almost boggy consistency, yielding when pressed upon firmly with a 
blunt-pointed probe and readily penetrated by a sharper instrument. 
The English compare its contents with apple-jelly. 

The changes within, about, and beneath these lesions furnish prac¬ 
tically the clinical pictures of lupus vulgaris. Thus there may be 
extensive oedema, thickening, hypertrophy, hyperplasia (“ bouffissure,” 
pachydermia) even telangiectasis, and an accompanying lymphangitis 
or lymphadenitis (Lupus Hypertrophicus, Papillosus, CEdema- 
tosus, Elephantiaticus, Tumidus, Exuberaxs, etc.). In many 
of these cases the prominent symptom which has suggested these names 
to the older writers is in fact a simple inflammatory swelling, due 
only indirectly to the lupoid involvement of the skin, a fact which 
can be recognized after any efficient treatment of an extensive plaque 
of lupus of the face, the subsidence of the swelling being one of the 
most conspicuous of the immediate results of the treatment. 

Involution of the lupoma, or of tissue infiltrated with lupoid cells, 
occurs by resorption of that material, by fibroid metamorphosis, and 
by ulceration. These several changes separately or together furnish 
other clinical pictures of the disease. Thus the lupus lesion or patch 
may furnish scales, whitish, dirty, yellowish-brown, or even glistening, 
the epidermis above and about becoming wrinkled. This process may 
be central or peripheral as respects patch or lesion, leaving eventually 
a cicatriform depression in the skin (Lupus Exfoliativus, Lupus 
Psoriasiforme, “ Lupus-Psoriasis ”). When a fibrous metamor¬ 
phosis occurs a sclerotic mass occupies the site of the former lupoid 
tissue, which in some cases progresses to extension of the lupoid patch 
in consequence of the farther production of the toxin of the bacilli in 
the site affected; and in others furnishes a final result in the produc¬ 
tion of the cicatriform tissue resembling that left after involution with¬ 
out ulceration of the gumma of syphilis. (Lupus Sclerosus, Scl£- 
reux, Fibrosus.) 

In the degenerating forms of lupus ulceration may begin by break¬ 
ing, down of the epidermis over the lupus tissue, or by a more or less 
rapid transformation of patch or lesions into a cheesy semi-purulent 
mass of detritus. When pus is freely formed, whether superficially or 
deeply, crusting ensues, the debris of epidermis being entangled with the 
desiccated secretions. These crusts are variously colored and differ in 
thickness with the severity of the degenerating process beneath. The 


NEW-GROWTHS. 


567 


oval or roundish ulcers which furnish them are usually well defined 
as to the margin, shallow, thin-edged, and flattish; and their floors are 
dirty-reddish or purplish, indolently granulating, furrowed, hemor¬ 
rhagic, or, when cicatrization is in progress, healthy. The destruction 
produced by involution of a lupous patch may be both by resorption 
and ulceration in the same subject and at the same time. The two 
processes may also coincide with an outbreak of fresh lupous tubercles, 
which latter may develop at one point or another of the patch under¬ 
going involution, probably from emigration of bacilli at the point of 
advance. In other cases lupus may spread by the formation of fresh 
nodules and plaques separated by islets of sound skin from those pre¬ 
viously degenerated. When the ulceration advances it may be super- 
fic : al, deep, or have other peculiarities and be subject to other accidents 
of the ordinary process of ulceration, whence the names Lupus Ser- 
piginosus, Profundus, Superficial^, Gangrenosus, Exulcer- 
ans, Rodens, etc. 

Lupus Crustosus and Rupioides are terms descriptive merely of 
the incrustations which form in some cases. Exuberant granulations 
elevating the floor of the ulcer may produce the condition termed 
Lupus Eungosus, Lupus Fungoides, Lupus Vegetans. Lupus 
Keloides indicates a cicatricial overgrowth of the scar-tissue left after 
anv one of the several conditions described above.' 

One of the most conspicuous features of lupus vulgaris is its essen¬ 
tially chronic course. It requires far more time for its complete evolu¬ 
tion than either syphilis or carcinoma; and in this point is best 
compared with lepra. For a quarter of a century a lupous patch may 
be limited to a space no larger than the palm of the hand, and exhibit 
some evidence of activity during the greater part of that period. 

Lupus of the Face. Here the first manifestation is the so-called 
primary efflorescence, exhibited on one or both cheeks, nose, or cheek 
and nose, as a dull-colored maculation or minute nodule, often long un¬ 
noticed, or as a finger-nail-sized, purplish thickening of the skin. Ex¬ 
tension may then occur by multiplication of the lesions, or by spreading 
of the single patch, the central parts wasting or cicatrizing. The 
contracture of the irregular scars thus resulting may produce an ectro¬ 
pion of the lid or lip, and with this is often seen the “ bouffissure ” 
of the features, already described. Crusting and ulceration may be 
conspicuous or well-nigh absent features. Gradually the subcutaneous 
tissue becomes involved. 

The nose may, after absorption of the lupous tissue, become shrunken 
and retracted to a miniature of its former dimensions, its tip being 
noticeably reduced to a sharp point, producing thus a characteristic 
deformity suggesting the beak of a parrot. In other cases the point 
becomes bulbous, flattened, livid, and knobbed, with a thickened sep¬ 
tum and distorted ala 3 , an isolated patch or two of lupous infiltration 
showing in the neighborhood of the cheek on one or both sides. The 
last described condition may lead by degenerative processes to the first, 
but is more commonly noticed as a less severe and more localized 


568 


DISEASES OF THE SKIN. 


involvement of the face, which may terminate, in favorable cases, 
without the severe mutilation first described. 

The subcutaneous tissue, mucous membrane, cartilages, and bones 
may be destroyed ; and in place of the nasal organ itself there may be 
left eventually two ovoid cavities in the face, separated merely by the 
posterior flange of the septum. 

Often large portions of the skin of the head (cheeks, lips, nose, lids, 
chin, ears, brow, and neck) become altered by the lupous growth. The 
resulting thickening produces a marked and characteristic deformity, 
reducing the openings of the mouth and lids to narrow slits, interfer¬ 
ing with vision, speech, and mastication, and producing a marasmus 
from these causes alone, before there is ulceration at a single point. 

The ravages of the disease are at times frightful in severity; not 
merely in consequence of the destructive ulceration to which it tends, 
but from the deformity left by awkward attempts at repair. The entire 
head may be thus converted into a hideous travesty of humanity, while 
yet its possessor is left with all his vital organs and functions appar¬ 
ently unimpaired. 

The upper lip, when involved, becomes first swollen, fissured, hem¬ 
orrhagic, and crusted; and a granulating surface indicates extension of 
the disease to the adjacent mucous surface. Later, if the ulcer heal, 
the mouth, by contracture, is reduced to a repulsive-looking slit or 
chasm in the face, permanently retracted, and either open or closed. 
The gums, lining meinbraue of the lips, velum, and hard palate may 
be also granulating, eroded, or whitish, when the exfoliated epithelium 
is in situ. Ulceration and cicatrization here also produce deformities 
interfering with the function of the parts, aphonia, for example, result¬ 
ing from the operation of these causes in the larynx. 

Lupus Vulgaris of the Ears may be symmetrical in develop¬ 
ment, or affect but one auricle. As in eczema, a favorite point of 
election is the lobule, which, with or without tumefaction of the whole 
organ, becomes a pyriform, purplish, dependent tumor, agglutinated 
speedily to the cheek. Later, when ulceration occurs, the auricle may 
disappear, or be reduced to a shrunken shell of its former state, the 
external auditory meatus being, by the same process, occluded. 

Lupus of the Trunk is, as a rule, more extensive and less destruc¬ 
tive than lupus of other parts. Giant areas over the loins, hips, and 
belly may be involved in superficial, serpiginous ulceration, the centre 
healing as the peripheral ring spreads. In these cases it is even more 
difficult than in others to insure cicatrization. 

Lupus of the Genital Region may occur in both sexes and 
then, as a rule, has extended thither from affected areas of the adjacent 
integument. 

Lupus of the Extremities is remarkable for its interference 
with the mobility of the smaller bones of the hands and feet, as a 
result of rigid cicatrices, and also for the production of caries and 


PLATE IX. 



Lupus Hypertrophicus of the Face. 

[From a photograph ot one of the author’s patients.] 












NEW-GRO WTHS. 


569 


osseous necrosis. Mutilating effects are thus produced by loss of 
phalanges, and also by shortening of the hand or foot after the destruc¬ 
tion of centrally situated bone. Elephantiasic enlargement of such 
organs as the hands and feet thus corresponds to the livid tumefaction 
seen occasionally in the face. Thickenings, ridges, knobs, nodules, 

Fig. 67. 



Lupus vulgaris ot the leg. (From a photograph.) 


warty excrescences, ulcers, crusts, and callosities are often commingled, 
and in patients of mature years strongly resemble some forms of vege¬ 
tating and ulcerating epithelioma. 

Lupus of the Mucous Membranes may or may not mean exten¬ 
sion of the disease from an affected adjacent integument. The lupous 
nodule, in consequence of warmth and moisture, is here transformed 
into a moist papillary outgrowth, or externally granulating patch which 
may ulcerate and cicatrize. The borders of such an affected area are 
well defined, and its surface is reddish and florid, quite pallid, white 
and glistening, or of a dirty grayish-white color, where the investing 
epithelium is loosened but not yet detached. 

The soft is rather more often involved than the hard palate, but 
these parts with the tongue, larynx (epiglottis, inter-arytenoid fold), and 
gums may be extensively invaded. Often for from two to five years 
the disorder may make no apparent advance, being limited to patches 
of red, swollen, coarsely granulating, whitish or glistening mucous 
membrane, with ulcerating and cicatricial processes slowly resulting. 
The lymphatic glands beneath the jaw and in the subclavian region 
may be simultaneously enlarged. In connection with the character¬ 
istic lupoid nodules grayish growths of the character of small tumors 
may be recognized in the larynx, with the result of partial occlusion 
of the rima glottidis. Patients may suffer from apical pulmonary 
tuberculosis, presumed to be the result of extension of the disease 
from laryngeal lupus. 

Under the title “ Lupus Demisclereux de la Langue” Leloir 1 


1 International Atlas of Rare Skin Diseases, 1889. 





570 


DISEASES OF THE SKIN. 


pictures and describes the features in the case of a girl fifteen years of 
age, with lymphatic adenopathy, typical lupoid nodules about the nose, 
and characteristic u parrot’s beak deformity” of the latter. The 
middle of the dorsal surface of the tongue displayed smooth, pea-sized 
and larger sclerotic nodules, grayish-yellow, firm and softish, separated 
by furrows, and non-ulcerative. The palate, uvula, and larynx were 
involved. Tubercle-bacilli were recognized and cultivated in series, 
and inoculation of the cultures produced tuberculosis in guinea-pigs 
and a rabbit. 

Esthiomene (so-called Lupus of the External Genital Organs of 
Women). In the year 1849 Huguier published a report of cases under 
the title of esthiomene, which have been the basis of a conception 
widely prevalent since that date that lupus of the vulva especially 
presents certain peculiarities not displayed by that disease elsewhere. 
The subject has lately been restudied with special care by several 
observers, including the author, and last, Dr. R. W. Taylor, of New 
York, who is in practical accord with the author on this subject. As a 
result, it may be stated that lupus of the genital organs in women does 
not in any special way differ from its manifestations in other regions of 
the body. The “ esthiomene ” of Huguier and his followers is a 
complexus of differing disorders, including many cases of syphilitic 
sclerosis, secondary lesions, and gummata; and hypertrophies of the 
genital organs due to chronic “ chancroid,” traumatisms, and inflam¬ 
mations of a simple character aggravated by filth. It is not known 
to be a tuberculosis of the vulva, though it is possible that some tuber¬ 
culoses may have been included in the category. 


2. Tuberculosis Cutis Verrucosa. 

There are several forms of tuberculosis of the skin in which lesions, 
differing both in appearance and career from those described in con¬ 
nection with lupus vulgaris, have been demonstrated to be the result 
of the encroachment of bacilli of tuberculosis upon the integument. 
The lesions exhibit for the most part a verrucous or warty appear¬ 
ance, and are well illustrated in the most distinctive clinical member 
of the group, the anatomical tubercle. In 1884 bacilli were first dis¬ 
covered in its mass, and in the year 1886 Riehl and Paltauf pointed 
out the connection of this lesion with cutaneous tuberculosis. 


[A] Verruca Necrogenica. 

(Post-mortem Tubercle, Dissection-tubercle, Anatomical 
Tubercle.) 

AYrruca necrogenica is a vesiculo-pustular or wart like symptom of 
cutaneous tuberculosis, situated usually on the hands, and resulting 
from contact with the bodies of the dead. 


NEW-GROWTHS. 


571 


This lesion was first named verruca necrogenica by Wilks. 1 It 
commonly occurs on the fingers of those engaged in the habitual 
handling or dissection of cadavers, and results from such professional 
contacts, from dissection-wounds, and from all accidental inoculations 
with tuberculous virus. Cases are reported where the lesion has had 
a non-cadaveric origin. It begins at the site of an abrasion or wound 
as a vesico-pustule, with deep-seated base and reddish or reddish- 
purple areola. This is productive of a burning, smarting, or pruritic 
sensation. The lesion accomplishes a period of bursting and crust¬ 
ing, which may be followed by a complete involution. Several isolated 
or grouped papules, nodules, or tubercles may 
be formed, one or a patch of several subse¬ 
quently undergoing atrophic changes over an 
area of several inches diameter. Dermatitis 
and suppuration, very rarely ulceration, may 
complicate the process. The typical so-called 
“ anatomical tubercle ” is indurated and horny. 

A pigmented verrucous papule or tubercle very 
slowly forms, which may become fissured at one 
or more points. The characteristic lesion is 
the thickened, indolent, more or less pigmented 
and fissured, split-pea to bean-sized wart, 
usually single, found on the finger of the 
anatomist. 

In other cases grave symptoms result, either 
in the involvement of the deeper tissues (sub¬ 
cutaneous, thecal, tendinous, periosteal), or in 
the production of erysipelas, pyemia, septice¬ 
mia, or gangrene. Surgeons divide these cases 
into mild and acute varieties, according to the 
symptoms exhibited. The records of the medical profession in almost 
every one of the large cities of this country contain the names of one 
or more of its eminent representatives whose lives have been sacrificed 
in this manner. In a few instances the local process has been fol¬ 
lowed by generalized tuberculosis. 


Fig. 68. 



Verruca Necrogenica. Model. 
Guy’s Mus. 193 50 . 


[B] Tuberculosis Verrucosa Cutis [Riehl and Paltatjf]. 

(Lupus Sclerosus, Lupus Scl£reux.) 

The lesions of this form of cutaneous tuberculosis occur often on 
the flexor aspect of the lower forearm, but also in other regions of the 
body, such as the integument covering the inner malleolus. The 
plaques are distinctly circumscribed, ovoid in outline, and usually 
covered with minute pustules, fine vegetations, and thin crusts. A 
characteristic violaceous halo commonly surrounds the whole. In 
these cases the papillary layer of the skin is chiefly involved. 


1 Guy’s Hospital Reports, third series, vol. viii. p. 263. 


572 


DISEASES OF THE SKIN . 


LC] Other Cutaneous Tuberculoses. 

An interesting series of morbid phenomena is presented when, for 
special reasons (proximity of tuberculoses of organs other than the 
skin, accidents of position and exposure, influences that escape detec¬ 
tion), sites of tuberculous infection, whether primary or secondary in 
order, exhibit peculiar special symptoms : 

Tuberculosis papillomatosa cutis (Morrow’s type) is by some 
authors assigned to verrucous tuberculosis (B). In these cases ex¬ 
uberant, soft, and florid excrescences rise to the height of one or two 
centimetres above the general level, closely packed together, with 
individual elements separated by deep fissures, the whole bathed in a 
puriform mucus concreting in dark crusts. 

Fibromatosis Tuberculosa Cutis (Riehl). In these cases there 
is not merely a papillomatous, but often a sclerotic growth found on 
the lips, nose, cheek, or about the anus or other mucous outlets of the 
body, interspersed with verrucous lesions, vegetations, and small shal¬ 
low ulcers. The tuberculous masses may be in the form of tumor¬ 
like bodies or thickenings of the subcutaneous tissue. 

Elephantiasis tuberculosa cutis is a term applied to gigantic 
overgrowths of the integument, complicated by lymphatic occlusion. 
In these cases there has usually been a blocking up of the lymph- 
channels by an infarction produced by leucocytes charged with tubercle- 
bacilli. 

Tuberculosis Fungosa Cutis (Riehl). In this class of cases 
tumors form resembling those occurring in mycosis fungoides, second¬ 
arily infected with tubercle-bacilli from other and usually adjacent 
organs (bone, muscle, etc.), the reddish-brown nodules first formed 
increasing at first to the size of a hen’s egg. These may surmount 
large areas of infiltration and ulceration. Beside the tumors, minute 
pustules, vegetations, and crusts may be seen. Eventually typical 
tuberculous ulcers form. 

Tuberculosis cutis serpiginosa ulcerativa is a term relating 
to a rare group of lesions in which brownish-red nodules, pea- to bean¬ 
sized, degenerate in the course of weeks or months until there results 
a centrifugally spreading, ovular or roundish, even horseshoe-shaped 
ulcer, grayish-yellow in hue and overspread with smaller cicatrices. 
Instead of nodules, the first lesions may be circumscribed areas of 
infiltration. The involved surface may be extensive, even larger than 
the two palms, and may coexist with secondary foci of involvement. 
Visceral and pulmonary tuberculosis may result. The resemblance 
of the large spreading patches to a serpiginous syphiloderm is striking. 

Lymphangitis Tuberculosa Cutanea (Besnier, Lejars). The 
lymphatic vessels of the skin may be either primarily or secondarily 


NEW-GRO WTHS. 


573 


invaded with tubercle-bacilli, and in either event linear lesions form 
corresponding to the lymphatic trunks, or there develop tuberculous 
nodules or warts, dermic or subcutaneous in situation, which event¬ 
ually ulcerate and discharge pus, blood, or lymph. At times a retic¬ 
ular network results, with fistulous sinuses. Several of the lymphan- 
giectases have been demonstrated to be tuberculous in character. 

It is chiefly important to note in this connection that accidental in¬ 
oculations with tuberculous material produce in different cases different 
clinical results, the essential part of the process being the transferrence 
of tubercle-bacilli. These infections are far more common than is gen¬ 
erally understood. They occur in both the young and the old. Fox, 
of London, has reported such instances at the ages of seventy-two and 
eighty-two, respectively ; and Mr. Marmaduke Shield has seen cases 
of general tuberculosis of the aged, resulting from these accidents. 


3. Tuberculosis Cutis Orificialis. 

The clinical forms included under this title were those once supposed 
to be the sole manifestations of cutaneous tuberculosis. The title 
u tuberculosis of the skin” was, in fact, applied exclusively by many 
writers to the lesions observed by Kaposi, Jarisch, Chiari, 1 and others. 
These were indolent, oval or circular, shallow, discrete, reddish-yellow, 
granulating ulcers, often covered with thin crusts, occurring about the 
mucous orifices of patients affected with pulmonary tuberculosis (lips, 
anus, and vulva) and with development of miliary tubercles in the 
adjacent mucous tract. Tuberculous lesions of ulcerative type on the 
alae of the nose, over the lips, and about the ear, have been recog¬ 
nized in association with laryngeal, palatal, oral, pulmonary, and 
intestinal tuberculosis. 

In the case of a patient in advanced pulmonary tuberculosis, lately 
shown, there was a tuberculous ulcer near the anus, and also a well- 
defined patch of infiltration in near proximity, highly suggestive of 
some of the forms of lupus. 

An acute tuberculosis of the skin in children has been described 
under different titles (dermatitis tuberculosa acuta, tuberculose pseudo- 
ulcSreuse) by Heller and Gaucher. In these cases macules, vesicles, 
bullae, papules, and pustules, terminating in deep, crusted, roundish 
ulcers and accompanied by caseation of neighboring glands, were found 
to contain bacilli; and inoculations of cultures resulted in sufficiently 
distinct tuberculous infection. These cases scarcely justify their sepa¬ 
rate classification. They are properly placed with the clinical forms 
of disease termed, for provisional purposes, scrofulosis of the skin. 


i Viertelj. f. Derm u. Syph., 1879. 


574 


DISEASES OF THE SKIN. 


4. Scrofuloderma. 

(Lat. serofa, a sow.) 

Scrofuloderma is a tuberculous affection of the skin and subcutaneous tissues, usually 
originating in the lymph-glands or the periglandular tissue, which after a pro¬ 
cess of infiltration and softening results in degeneration by ulceration. 

Symptoms. The term Scrofula, or Struma, has been long and loosely 
applied in general medicine for the purpose of designating a number 
of diseases the real significance of which was unknown, their points of 
resemblance to each other being greatly outnumbered by their specific 
differences. The researches of the last twenty years have been steadily 
and continuously restricting this list in almost every department of 
medicine. Many of the disorders once supposed to be scrofulous are 
now known to be syphilitic. Rickets, for example, is properly recog¬ 
nized to-day as a manifestation of hereditary lues. In orthopedic sur¬ 
gery a number of joint-affections once believed to be incontestably of 
strumous origin are known to be producible by traumatism exclu¬ 
sively. And in dermatology, no less, a broad advance has been made 
since the day when eczema, psoriasis, and acne were described as evi¬ 
dences of scrofula. 

The term scrofuloderm is here strictly limited to those cutaneous 
changes which occur in distinctly scrofulous subjects, and which are 
the result of tuberculous infection. Billroth's description of the scrof¬ 
ulous diathesis may here be recalled. By this term he recognized that 
condition in which there occurs at any point in the body where irrita¬ 
tion has been induced an indolent inflammation which persists after 
such irritation has ceased, which frequently terminates in suppuration 
and caseation, aud which subsequently rarely pursues a hyperplastic 
career. If with this be conjoined inflammation and caseous infiltration 
of the lymphatic ganglia or of the subcutaneous connective tissue; 
amyloid degeneration of one or several of the viscera; tumefaction of 
the belly; chronic keratitis, ophthalmia, otorrhea, or coryza; a chronic 
arthritis (white swelling); a pasty, dirty-colored and thick, or delicate 
and transparent skin exhibiting cicatrices of old abscesses or ulcers, 
the general picture of the scrofulous patient may be considered com¬ 
plete. The recognition by Robert Koch of the etiological importance 
of the bacillus tuberculosis in tuberculous disease, and the demonstra¬ 
tion of the presence of these micro-organisms in a number of lesions 
heretofore regarded as “ scrofulous,” have placed this problem at last 
upon the basis of satisfactory proof. The word “ scrofuloderm ” 
should be hereafter strictly limited in its application to those lesions 
of the skin and subcutaneous tissue in which tubercle-bacilli have been 
or can be demonstrated. 

The scrofulodermata are all characterized by the occurrence of path¬ 
ological processes in the skin, lymph-glands, or periglandular tissues, 
which betray the evidence of the scrofulous process. They usually 
begin as firm, well-defined subcutaneous nodules, similar in type to the 
syphilitic gumma, which gradually enlarge, become attached to the 


NEW-GROWTHS. 


575 


skin, subsequently degenerate, exhibit characteristic ulcers, and usually 
terminate by no less characteristic cicatrices (“ Gommes Scrofuleuses,” 
u Gommes Sorofulo-tuberculeuses,” “ Scrof uloma”). 

The typical scrofuloderm is encountered about the face and neck, 
where the lymphatic glands have long been tumid, and either dense 
or doughy to the touch. This condition is usually reached very 
slowly; often months and years are required for its production. The 
glands may be as small as almonds or as large as the closed fist. 
Gradually a scrofulous dermatitis ensues in the skin which is super¬ 
imposed. It becomes purplish and thinned and finally yields, giving 
exit to a sero-purulent fluid mingled with caseous matter and blood. 
The pus-corpuscles of this fluid, examined under the microscope, are 
seen to be poor in protoplasm. Fistulous tracts and sinuses result, 
which undermine and perforate the skin, resulting in the formation of 
a chronic discharge and characteristic ulcers. The latter are far more 
remarkable for their borders and bases than for their floors. They are 
usually linear, occasionally elongated and oval, almost never circular. 
As a result, their uneven floors, covered with pallid granulations and 
a watery pus, are often hidden beneath their inverted, tumid, and 
uncolored edges; or the latter may be thinned, stretched over a fistu¬ 
lous pocket, and reddish or purplish in color. Their bases are usually 
deeply attached to the subcutaneous tissue, and are firm or soft, never 
densely indurated. The resulting crusts are thin, tenacious, reddish 
or brownish, and, like the ulcer, often linear, rarely bulky, never 
rupioid. The resulting cicatrices are corded, depressed in irregular 
lines or bands, and often alternate with equally irregular nodules 
(scrofulous gummata), where the degenerative process either has been 
arrested or is still in activity. 

Rarely, enormous ulcers originate in the manner described above, 
which dissect out vast areas of subcutaneous and intramuscular tissues 
in the neck or even the extremities, in the course of which cartilage, 
bone, and periosteum are melted away. Usually but a few of these 
points of degeneration, from two to six, are exhibited in one patient. 

Tuberculous Dactylitis, observed generally in children, is char¬ 
acterized by bulbous extremities of the fingers and toes, the skin 
covering the same being at times the seat of infiltration and thickening. 
Dr. White (1. c.) believes this process to be more common than that 
occurring in dactylitis syphilitica. 

Suppurative Tubercular Lymphangiectasis (Hallopeau and 
Goupil) is a condition in which scrofulo-tuberculous gummata, in 
small-nut- to egg-sized tumors, form along the lymph-vessels, of the 
lower extremity particularly. When such a tumor breaks down it fur¬ 
nishes the typical picture of the scrofulous ulcer, with its cheesy and 
watery pus, its thin edge, and its indolent career. In these rare cases 
bacilli have been recognized in the secretion. 


576 


DISEASES OF THE SKIN. 


The Dermatoses of Scrofulous Subjects. 

In this connection it is desirable to consider a few cutaneous disor¬ 
ders which, while recognized as of occurrence among the scrofulous, 
exhibit lesions which, at the present time, have not been determined 
to be sites of bacilli. Of this small group it may be remarked that 
they are but little represented in the records of the general practitioner. 
They have been observed either for the most part on the Continent of 
Europe or by but a few experts in America. 


Lichen Scrofulosorum. 

This eruption, first described by Hebra, 1 is characterized by its 
chronicity, and the occurrence chiefly upon the trunk, back, and 
belly, of millet-seed- to pin-head-sized, firm, flat, light- to livid-red, 
and grouped papules. These are occasionally surmounted at the apex 
by a minute scale, rarely by an equally small pustule. The lesions 
are at the onset isolated; later they tend to arrange themselves in 
coin-sized patches; when evolution is accomplished they are closely set 
together, the surface of the skin being then of a dirty reddish-brown 
color, and covered by thin scales which are readily detached. Often 
a crescentic outline can be determined in a group of aggregated lesions. 

The course of the eruption is slow; often the cutaneous symptoms 
persist for months without apparent change, awakening little or no 
pruritus, and are followed by involution, accompanied by slight 
desquamation and no cicatrices. 

In 99 per cent, of all cases observed in Austria there was concomi¬ 
tance of the general symptoms of struma named above (submaxillary, 
cervical, and axillary adenopathy, periostitis, ulcerative dermatitis, 
etc.), with frequent complications, such as eczema of the scrotum and 
acne cachecticorum. The disease was encountered in young strumous 
patients between the periods of infancy and puberty, never after the 
twentieth year. 

According to Kaposi, the disease consists in an exudative infiltration 
of the pilo-sebaceous follicles and the perifollicular tissue. Each 
papule represents, therefore, the orifice of a follicle, with an infiltrated 
perifollicular annex; and its apical scale or pustule is formed of a 
mass of epithelial d6bris or an inflammatory exudate. 

The disease is readily differentiated from papular eczema by the 
absence of itching. From the miliary papular syphiloderm it differs 
in that the lesions of the latter, even though grouped, are always indi¬ 
vidually distinct. The general symptoms, moreover, are strikingly 
different in the two diseases. Lichen scrofulosorum cannot be con¬ 
founded with lichen planus or lichen ruber. Lichen pilaris, however, 
in a young and lymphatic patient, might readily be mistaken for the 
disease in question. 

This scrofuloderm is rare outside of Austria. 


1 See his remarks before the German Surgical Society, Fourteenth Congress. 


NEW-GROWTHS. 


577 


Folliculitis of Tuberculous and Scrofulous Subjects. 
Under this head may be included provisionally a group of phenomena 
occasionally seen on the skins of patients affected with tuberculosis or 
scrofula. By some English and French dermatologists these cases have 
been reported as forms of lichen scrofulosorum. By other observers 
they have been given differing titles, such as pustular scrofuloderm, 
tuberculosis suppurativa et bullosa acuta , etc. 

The lesions occur as inflammatory papules or pustules of an evident 
follicular origin. In some cases vesicles and bullae have been com¬ 
mingled with the other lesions. The lesions may be small or large, 
few or numerous, limited to one or two well-defined patches or regions 
or, as is more commonly the case, diffuse or irregularly grouped. In 
some of the milder circumscribed cases the manifestations are limited 
to a few scattered or grouped papules and pustules situated about the 
hair-follicles. In other instances the lesions are larger, may coalesce, 
and be covered with more or less bulky crusts beneath which ulcers may 
form. As a rule, the course of the disease is slow and the lesions are 
indolent in type. Occasionally the symptoms are more acute. In the 
majority of cases the folliculitis is evidently due to a local infection 
with pus-cocci in tissues having but feeble powers of resistance. In 
some instances, however, the local infection seems hardly sufficient to 
explain the appearance of the skin. 

An Acne Group of Tuberculoses. An acne group of tubercu¬ 
loses results from the common habit of picking and scratching the 
scalp, face, and beard. The finger-nails in these cases, especially 
when there is tuberculosis of the pulmonary organs of some member 
of the same family, are probably the carriers of tubercle-bacilli. 
These micro-organisms have been recognized in a number of acne 
lesions, and were at first supposed to have no significance in this 
situation. The “lupoid sycosis’’ of certain writers refers to a class 
of cases which may be regarded as distinct from the simpler varieties 
of sycosis, since in the “ lupoid” forms lesions persist for several years, 
and finally leave atrophic and scar-like or simply wasted lines, points, 
or areas in the region of the male beard. Some of the disorders of the 
scalp termed “ epilating,” “ cicatricial,” “ unnamed,” “ follicular and 
perifollicular,” and “ neurotic” alopecias, may be one day assigned 
to this class of tuberculoses, since already bacilli have been recognized 
in some of them. 

Ulerythema Acneiforme [Acne Necrotica]. Under this title 
Unna 1 describes and figures a disease on the face of a young girl, begin¬ 
ning with the production of papules in the centre of the cheek, where 
finally developed comedone-like masses; the lesions without suppura¬ 
tion, eventually left reticulated and pitted scars perceptibly sunken and 
traversed by dull-white ledges between which comedones were visible. 
The lesions were also visible about the scalp, forehead, and ear. 
Anatomically it appeared that inflammatory symptoms resulted in a 
perifollicular cell-infiltration, with dilatation of lymph-spaces and 

i International Atlas of Rare Skin Diseases, i. 1889. 

37 


578 


DISEASES OF THE SKIN. 


consequent changes in the epithelium, as well as in the muscular, elastic, 
and other tissues. Unna does not seem to have suspected this to be a 
form of tuberculosis, as the latter is not named in giving a differential 
diagnosis; and it does not appear that search was made for bacilli, 
though he asserts that it is “probably parasitic/’ 

The disorder thus named represents a class of cutaneous tubercu¬ 
loses many of whose manifestations resemble those of acne. A series 
of these, studied with special care, reveals the nature of the process 
in which tubercle-bacilli may be recognized. In an extreme case of this 
kind under observation for several years the face had been extensively 
disfigured with similar scars interspersed with comedone-like masses. 
There was a history of tuberculosis in two members of the same family. 

In all these cases there is the same cycle of symptoms, inflammatory 
redness with local distress, infiltration, absence of suppuration through¬ 
out, no distinct ulceration, and eventually cicatricial atrophy, the scars 
very slightly, if at all, resembling those left after other processes. 

“ Tuberculous Eczema” (of Unna) is merely an exudative affec¬ 
tion, which may be recognized in proximity to the scrofulodermata, 
a process awakened by the irritative effects of the latter; or the dis¬ 
ease occurs, as do other affections, in scrofulous patients. 

Erythema Induratum (Eryth^me indur6 des Scrofuleux—Bazin). 
This disorder affects chiefly the lower extremities of young persons, 
especially girls, who have been accustomed to the erect posture for 
long periods of the day and who exhibit as well unmistakable symp¬ 
toms of scrofula. The special circumstances in which this form of 
indurated erythema is produced are, primarily, a somewhat enfeebled 
constitution, and, as a secondary or exciting cause, toil in the standing 
position, as for example, among laundresses and shop-girls. 

The symptoms are declared in acutely developed or indolent, single 
or numerous, vividly red or purplish-hued, node-like patches on the 
front and calf of the legs or over the thighs, or even upon the upper 
extremities (Crocker). At times a single patch extends by multipli¬ 
cation or by spreading from an original site till a broadly infiltrated 
plaque is formed, somewhat suggestive of the lesions of erythema 
nodosum. The firm induration of the node is one of its striking 
features. The nodules may be either superficially or deeply situated ; 
painful and tender or quite insensitive, the last being the rule; and 
may undergo a tedious involution or degenerate and produce ill-condi¬ 
tioned ulcers. Frequently it is impossible to distinguish clinically 
between these nodes and ulcers and those of syphilis ; the diagnosis 
must then rest upon the history and concomitant lesions. There is, 
as a rule, absence of constitutional symptoms and especially of fever, 
an important point in the distinction between this affection and ery¬ 
thema nodosum. Relapses are not infrequent. The disease is rare, 
occurring chiefly in public practice. 

The tuberculous nature of the lesions has not been determined 
definitely as yet by the discovery of tubercle-bacilli, though these have 
been reported in one or two instances; but coexistence of the disease 


NEW-GROWTHS. 


579 


with enlargement and in some instances with suppuration of the lym¬ 
phatic glands of the subject of the malady justifies the title given it 
by French observers. 

Treatment is by administration of the remedies most efficiently 
employed in cachexia and struma, with a generous diet, a recumbent 
position of the lower extremities when these are the seat of the disease, 
and the ordinary management of chronic ulceration of the skin of the 
legs when such lesions are present. In a few cases the iodid of potas¬ 
sium has been given with advantage when there was no suspicion of 
syphilis. 

Lupus Erythematosus (consult the following chapter) is by some 
authors classed with the disorders grouped under the title of tubercu¬ 
losis cutis. The evidence that it is itself a cutaneous tuberculosis is 
not satisfactory. That, however, it may be in some cases a dermatosis 
of the scrofulous can scarcely be questioned. Hallopeau and Jean- 
selme, 1 for example, report the case of a man thirty-five years of age, 
tuberculous from early life, with characteristic cicatrices of a gangli¬ 
onic scrofulosis visible in the skin and no less characteristic adenop¬ 
athy of the neck, perishing eventually of miliary tuberculosis, who had 
characteristic patches of erythematous lupus on the face. Histolog¬ 
ical examination revealed no bacilli in the lupous tissue, and the results 
of inoculations were wholly negative. Other equally significant records 
have been made. 

The evidence, as regards some of these forms, which may be classed, 
perhaps, with the u pseudo-tuberculoses,” is instructive. The results 
of inoculation of tuberculous material in different lower animals seems 
to establish the fact that scrofuloderma, tuberculosis cutis, and lupus 
vulgaris differ widely in the number of bacilli that can be recognized 
in their respective lesions. It is, hence, argued that with even fewer 
micro-organisms present there may exist types of tuberculosis still 
further removed from those here classified. 

Etiology of Cutaneous Tuberculosis. Accidental inoculation of tuber¬ 
culosis may occur at all ages and in all sexes. There is, however, 
ampler opportunity for such transmission among the members of any 
family where pulmonary tuberculosis exists; hence the widespread be¬ 
lief in the heredity of the disease. Attention has, however, been 
already directed in these pages to the striking fact that children are 
rarely born into the world tuberculous; and the possibility of explain¬ 
ing all cases of reputed inherited tuberculosis by transmission from 
the actually infected can never be ignored. 

Given, however, an infective micro-organism, the soil upon which 
it may flourish most favorably is of paramount interest in an etiolog¬ 
ical view. The young, the delicate, the cachectic furnish such a cul¬ 
ture-field. With these must be included, as favoring such accidents, 
the mode of life of the very poor, the filthy, and the degraded. 


i Annales de Derm, et de Syph., 1891, t. ii. 8-9. 


580 


DISEASES OF THE SKIN. 


Thus, lupus vulgaris is seen to be declared first in the majority of 
all cases during the first decade, between the third and sixth years of 
life ; rarely after the thirtieth year, for the reasons above given. The 
significant fact in this connection is that at this period of life the 
child often deprived of the constant care of a mother by the demands 
made by a still younger infant, untaught in the simplest rules of 
cleanliness, picking and scratching the face after miscellaneous con¬ 
tacts of the fingers with all sorts of material, is exceedingly liable to 
inoculate the skin of the face with tuberculous virus, if there be 


Fig. 69. 



victims of such disease occupying the same apartment or house. It 
is significantly first upon the face in these early years, and next over 
parts such as the extremities or the genital region, to which the ex¬ 
posed hands have been carried, that the early symptoms of lupus vul¬ 
garis are betrayed. T'urther, it is significant that well-marked cases 
are more frequent among the poor, the filthy, and the degraded than 
among the comfortable and cleanly. The prevalence of the disease 
in public as contrasted with private practice is conspicuous in all 
statistics. 



NEW-GROWTHS. 


581 


As throwing additional light upon the question of childhood infec¬ 
tion, it is to be noted that other forms of tuberculosis occur at any 
period of life and in both sexes, when the accident of infection oper¬ 
ates. Thus in verruca necrogenica and warty growths of the same 
nature, it is the contact with the bodies of the dead or with tubercu¬ 
lous matter in any form, which determines the result. The aged with 
tuberculous lesions upon the backs of the hands, middle-aged persons 
with other evidences of cutaneous affection, actually suffer from gen¬ 
eralized tuberculosis as a result of the accident. 

What may be said of the causes of lupus vulgaris relates also to scrof¬ 
uloderma, which, while occurring in both sexes and at all ages, is more 
frequent in earlv life because of the susceptibility of the tissues at 
those periods. The difference between the manifestations of scrofulo¬ 
derma and those of other clinical forms of tuberculosis depends in 
large part upon the attenuation of the virus, seeing that relatively 
fewer tubercle-bacilli are to be recognized in the characteristic lesions 
of scrofula; and the results of inoculations of cultures as respects the 
lower animals are markedly different. 

The soil fittest for scrofulodermatous manifestation is that where 
well-known agents have been most efficiently at work. All causes 
which tend to impair the nutrition and vigor of the body are, to an 
extent at least, efficient in its development, including privation from 
sunlight, fresh air, wholesome food, exercise, and hygienic influences 
in general. It is common among prisoners, exiles, and, in this 
country, among negroes and those of mixed blood. Consanguineous 
marriages are said to result often in strumous offspring. Syphilis 
in the third and fourth generations is known to be pathologically dis¬ 
tinct from all the manifestations of scrofula. In many cases scrofulo¬ 
derma is the sequence of other depressing medical diseases and surgical 
accidents. In certain instances, especially where it is limited to the 
neck, and accompanied merely by a cervical or submaxillary adenod- 
athy, scrofulosis is consistent with full vigor and nutrition of the body 
and all other evidences of sound health. 

Pathology of tuberculosis cutis. There is no longer any doubt in the 
minds of the great majority of observers that lupus vulgaris, tubercu¬ 
losis cutis verrucosa, and scrofuloderma, as well as tuberculosis cutis 
orificialis (the one form hitherto recognized as tuberculous) are due to in¬ 
fection with tubercle-bacilli, and are practically identical histologically 
with tuberculous lesions in other organs of the body. The discovery 
of bacilli in lupous tissue, first made by Koch, has since been verified 
bv Doutrelepont, Weichselbaum, xWeisels, Schuller, Lustig, and others. 
The striking resemblance first shown by Virchow between a caseous 
miliary tubercle and a lupous nodule had, even before Koch’s discovery, 
pointed to an identity of origin. The result of inoculation of culture- 
fluids has given positive results. Lenz, Hiiter, Schuller, and many 
others have produced tuberculosis in rabbits by introducing within 
the eye granulations taken from lupous, scrofulous, and other infected 
patients. 

For a knowledge of the microscopic characters of cutaneous tuber¬ 
culosis we are largely indebted to the Germans, whose opportunities 


582 


DISEASES OF THE SKIN. 


for the study of the disease are unequalled. Virchow, Auspitz, Bill¬ 
roth, Lang, Kaposi, Klebs, Stilling, and Thin have amply contrib¬ 
uted to the subject. 

The essential lesion in all forms of cutaneous tuberculosis is the 
nodule of so-called granulation-tissue, containing small round cells 
deeply stained by coloring-agents ; large cells, epithelioid in type, which 
contain one or more large clear nuclei; and giant cells having a homo¬ 
geneous centre and few or many large vesicular nuclei situated for the 
most part along the border of the cell. Around and between these 
cellular elements is woven a network of connective-tissue bundles. 
In its early stages the nodule is about the size of a millet-seed, is 



Section of lupus of face. X 750 and reduced. (Delafield and Prudoen.) 


grayish or reddish-yellow in color and translucent, is situated wholly 
within the corium, is well defined in outline, and is well supplied with 
vessels. After a shorter or longer period, depending upon the activity 
of the process, the nodule undergoes changes. Although there is 
marked proliferation of the endothelium of the vessels, no new vessels 
are formed, the old ones become obliterated, and there results a necro¬ 
sis—known as a coagulation-necrosis, or cheesy degeneration—of both 
cells and intercellular substance. In this condition the protoplasm is 
seen as a granular or amorphous mass, while the nuclei stain but feebly, 



NEW-GROWTHS. 


583 


if at all. Extension of the disease from the primary nodule may occur 
in the form of other circumscribed nodules, or as a diffuse infiltration 
of the tissues with the cell-forms above described, the small round cells 
being greatly in excess of the others. 

The process begins in the corium and extends to the epidermis and 
to the subcutaneous tissues, these adjacent structures being variously 
affected in the different forms of cutaneous tuberculosis. The epider¬ 
mis may be hypertrophied, exfoliating, or broken through by the tuber¬ 
cular infiltration, producing the typical ulcer. The nodules may soften 
and break down into a semifluid mass, and suppuration—always the 
result of secondary infection—frequently occurs. 

Tubercle-bacilli have been found in all parts of the nodule, both 
within and without the cells, but are usually most readily found in the 
giant cells and in the outer portion of the nodule. Since giant cells 
and nodules of granulation-tissue are found also in other than tuber¬ 
culous processes, the only pathogenic feature of the tubercle structure 
is the presence of the tubercle-bacillus, though the coexistence of a 
large number of giant cells and nodules or groups of epithelioid cells 
leaves little doubt as to the diagnosis. 

In lupus vulgaris are found the characteristics of the chronic and 
slowly developing forms of tuberculosis. Giant cells are numerous, 
the infiltration of round cells is marked, but epithelioid cells are pres¬ 
ent in comparatively small numbers, while the bacilli are very scarce 
in this tissue, many sections of which may be examined before finding 
a single bacillus. In lupus, more than in other forms of cutaneous 
tuberculosis, the proliferation of cells leads to a constructive or regen¬ 
erative process as a result of which the lupous nodule may be replaced 
by scar-tissue, or there may be an excessive formation of new connec¬ 
tive tissue, producing the various degrees of elephantiasis so often seen 
in lupus. This intermingling of new tubercular foci of infiltration 
with hyperplasia of connective tissue is what produces the many clinical 
forms of the disease. When the disease is extending, the new-growth, 
spreading along the vascular elements of the derma, involves finally 
the rete and the panniculus adiposus. The nest-like agglomerations 
disappear; there is in their stead an irregularly diffuse infiltration, 
producing subsequently hypertrophic, atrophic, desquamative, suppur¬ 
ative, or ulcerative sequels. Finally, the glands of the skin may 
become involved, the hairs falling from their follicles, the sebaceous 
glands either becoming obliterated, or having their acini stuffed with 
epidermal masses which distend them in milium-like bodies grouped 
about a cicatricial pedicle. 

The epithelium is secondarily involved in lupus and may be desqua¬ 
mating, atrophied, or ulcerated. Not infrequently there is marked 
proliferation of the epithelial cells with down growth of the inter- 
papillary processes. True epithelioma may thus result, in which event 
its course is usually rapid and destructive. There may be also a pro¬ 
liferation of the glandular elements of the skin. Leloir describes, as 
of rare occurrence, a colloid and a mucoid degeneration of the lupous 
tissue. 

In the verrucous forms of cutaneous tuberculosis the tuberculous 


584 


DISEASES OF THE SKIN. 


process proper usually is situated chiefly in the upper part of the corium, 
and there is more or less hypertrophy of the papillae and of the epi¬ 
dermal layers. In the well-marked cases of anatomical tubercle 
described by Rielil and Paltauf the horny layer is greatly thickened 
and shows cells in which the nuclei stain more or less, while between 
the layers of the cells are seen granular masses and the dried pro¬ 
ducts of exudation. In places the horny layer dips down to fill the 
interpapillary spaces. The papillae may be greatly hypertrophied and 
between them the rete may send projections deep into the corium, in 
which occasionally are seen crypts filled with horny masses of epi¬ 
thelium. Secondary inflammatory changes and pus infection may occur 
as in lupus. 

Between typical verruca necrogenica and the ordinary type of 
lupus vulgaris transitional forms are frequently seen which make it 
impossible to draw a sharply dividing line separating these forms of 
cutaneous tuberculosis. In verruca necrogenica a history of direct 
infection is often obtainable and tubercle-bacilli are more numerous 
than in the lupous nodules, though much less abundant than in tubercu¬ 
losis cutis orificialis. 

In tuberculosis cutis orificialis , both in the number of bacilli present 
and in the type of lesion, there is an analogy with miliary tubercle of 
other organs. Large numbers of typical, circumscribed nodules are 
found deep in the corium; bacilli are numerous and easily demonstrated; 
the degenerative processes go on rapidly, the tubercles breaking down 
and coalescing to form masses of softened necrotic tissue which soon 
break through the epidermis to form an ulcer. About the borders of 
such necrotic areas new nodules are constantly forming and the whole 
process is rapid, as in acute tuberculosis of other tissues. 

The scrofulodermata originate in the subcutaneous tissues and involve 
the skin secondarily. The lymphatic glands or the tissues about the 
glands or lymphatic vessels become the seat of the tuberculous process 
which runs a subacute course, and finally break down into softened 
necrotic masses. Such areas of necrosis may remain indolent and 
superficial, or, in case a gland is involved, may be deep and extend 
by burrowing prolongations even to the bone. Sooner or later the skin 
over these softened masses becomes involved in a subacute inflamma¬ 
tory process and gives way, producing the typical ulcer with soft, 
ragged, and often extensively undermined edges. The presence of 
tubercle-bacilli and the success of experimental inoculations have 
demonstrated these subcutaneous processes to be tuberculous. The 
number of bacilli present varies greatly, being much larger than in 
lupus, but much smaller than in the orificial forms of cutaneous tuber¬ 
culosis. The relationship of the scrofulodermata to lupus is occasion¬ 
ally shown by the formation of typical lupous nodules near the border 
of one of these scrofulous ulcers, the result no doubt of inoculation of 
the skin with the discharge from the ulcer. 

Diagnosis of Cutaneous Tuberculosis. Epithelioma, though rarely 
resembling lupus vulgaris, is more often designated by that than by 
any other false title. Great confusion has arisen from the looseness 
with which several surgical authors have furnished illustrations of 


NEW-GROWTHS. 


585 


“ lupus exedens,” which were really pictures of cancer. But the latter 
is rarely a disease of early life, and when of early occurrence may not 
persist to adult years; the reverse of which is true in the majority of 
all cases of lupus. The nodules of lupus are absent in epithelioma, 
and the evolution of the disease slower, less painful, and, in its 
earlier periods certainly, of deeper situation. The ulcer of epithe¬ 
lioma is more often defined and single; its edges whitish, indurated, 
and everted; its floor uneven and glazed; its secretion scanty and 
occasionally fetid; its base a mass of indurated tissue. Lupous ulcers 
are often ill-defined and multiple; their edges soft and inconspicuous, 
neither everted nor undermined; their floors granulating and flattened; 
their secretion relatively profuse and generally odorless; their bases soft 
and pliable, though occasionally indurated. 

Tubercular, serpiginous, and ulcerative lesions of syphilis often 
resemble certain forms of lupus. In any doubtful case a history of 
infection, of other types of cutaneous disease, of mucous patches, of 
adenopathy, of abortions in woman, etc., should aid in the recognition 
of syphilis. The suspected lesions should be carefully examined for 
the purpose of distinguishing characteristic lupous nodules in the patch 
itself or in the periphery of any exfoliating area. In the case of an 
adult a long history of lupus can often be obtained; and it is worthy 
of note that syphilis with exceeding rarity displays for long periods 
of time a single exanthematous lesion or aggregation of such lesions 
in one part of the body exclusively. Lupous ulcers, often multiple 
and isolated, insensitive, rarely of well-determined outline (never reni- 
form or horseshoe-shaped), with supple, low edges, and reddish, smooth, 
hemorrhagic granulating floor, covered with crusts like soiled parch¬ 
ment of uniform thickness, do not resemble those of syphilis. The 
latter are often painful, single, circular, and clean-cut in contour, 
with firm, raised, infiltrated margins, and with offensive greenish and 
blackish crusts, resembling oyster-shells. The cicatrices of syphilis 
are elegant, smooth, delicate, superficial, circular, and, after pigmenta¬ 
tion has disappeared, dead-white in color. Those of lupus are irregular, 
indurated, deforming, yellowish-white, and reddish-yellow. Acquired 
syphilis is a disease of adult life; lupus commonly begins in childhood. 

The disks of psoriasis are distinguished from flat exfoliating patches 
of lupus vulgaris by the relatively large number of the former, by the 
nacreous lustre of the scales, the reddish hemorrhagic surface beneath, 
and the sites of election of the disks, usually on the extensor faces of 
the limbs. 

Lupus erythematosus is even more readily distinguished by its char¬ 
acteristics; including the absence of nodules, ulcers, and crusts, the 
superficial character of the morbid process, the scaliness, and occasional 
symmetry of the patches. An intermediate form between lupus ery¬ 
thematosus and lupus vulgaris has been described, but most cases so 
classed probably belong to the type called by Leloir u erythematoid 
lupus vulgaris,” in which nodules are temporarily absent. In all such 
cases typical nodules of lupus vulgaris develop sooner or later and 
confirm the diagnosis. The two diseases, unfortunately somewhat 
similar in name, are distinct in character. The so-called intermediate 


586 


DISEASES OF THE SKIN. 


forms may be instances of flat and scaling epitheliomatous infiltration 
going on to ulceration. 

In acne rosacea with a bulbous condition of the tip of the nose the 
redness is vivid; and the telangiectatic complications, with the sebor¬ 
rheic flux, are conspicuous points of difference from lupus vulgaris. 
There is, further, no ulceration and little scarring, and the patients 
have usually suffered from the disease only after arriving at maturity 
of life. The mucous surfaces are also spared. 

The diagnosis of verrucous growths of tuberculous nature is to be 
made after an investigation of the history of each case, which often 
includes a record of contacts with bodies or persons capable of com¬ 
municating the disorder. The epitheliomatous warty growths on the 
dorsum of the hands of elderly persons are not to be confounded 
with tuberculous lesions. In the former there is commonly a history 
of longer existence of the wart, and no record of suspicious contacts; 
while a careful search will usually determine epitheliomatous metamor¬ 
phoses over the cheeks or temples of the elderly man or woman with 
epitheliomatous warts on the hands. In the latter, too, the facial 
lesions are usually multiple fatty-looking scales, thicker in one part 
than another, resembling those of a severe seborrhea, but which are 
removed with some difficulty, and which then leave a bleeding surface 
beneath. 

In the orificial cases it must be remembered that tuberculosis of the 
viscera is a probable coincident disease. The microscope is usually 
needed for an exact diagnosis 

The acneiform and sycosiform tuberculoses, many of them instances 
of implantation of tubercle-bacilli upon simple lesions, are distin¬ 
guished by anomalous symptoms occurring where none such was to be 
expected. For example, a sycosis, apparently simple, leaves persistent 
disfiguring infiltrations, with scar-tissue and even ulcerative effects; 
the acne which should resolve, exhibits deep sunken cicatriform pits, 
or papules which ulcerate; the alopecia of the scalp, which at first seems 
to be of simple type, results in characteristic changes of the deep tissues. 

Treatment of Cutaneous Tuberculosis. The internal treatment of 
tuberculosis cutis is practically that indicated by the condition of the 
patient; inasmuch as no medicament is known to be capable, after 
ingestion, of relieving the victim of his local ailments. Of the articles 
in this category none will be more often indicated than cod-liver oil, 
the chalybeates. the bitters, the preparations of iodin, and possibly 
phosphorus. Fox praises iodid of starch. Iodoform and iodid of 
potassium have been recommended by Neisser, who employs the former 
in pills, each containing half a grain (0.033). Recently guaiacol and 
carbonate ot creosote, either of them, in 5-grain capsules, have been used 
with varying degrees of success. In London thyroid-extract has 
been given for cases of extensive tubercular disease of the skin with 
much seeming benefit, though no complete cures are reported. The 
hypophosphites are useful in many cases. Arsenic and mercury are 
powerless to prevent the extension of the disease. It is needless to 
add that a diet of the most generous character is to be supplied, and 
the rules of hygiene enforced. 


NEW-GROWTHS. 


587 


Patients of the tuberculous class manifest iu the highest degree the 
beneficial effects of a change of residence and climate—to the seashore 
or mountains from the interior valleys or plateau-lands; often the reverse 
for those who reside by the sea or in mountainous countries. It is the 
change which seems to produce the greatest benefit. A free supply of 
oxygen in an abundance of pure air and a life permitting of out-of- 
door exercise is of the highest importance. The thermal and other 
springs of several countries furnish resorts where the benefit received 
is proportioned to the salubrity of the climate rather than to the special 
advantages of the waters furnished. 

Unfortunately, a large number of the patients affected with lupus 
and scrofuloderma are the impoverished inmates of public charities or 
applicants to dispensaries, where these aids in the management of their 
ailments cannot be utilized. 

The local treatment of lupus vulgaris should have in view the 
removal of the morbid growth as painlessly and with as little resulting 
disfigurement as possible. These ends may be attained both by sur¬ 
gical measures and by chemical and other applications. 

The surgical procedure most frequently employed is curetting with 
a sharp spoon. This, with all other bloody operations in lupus vul¬ 
garis, labors under the disadvantage of the possibility that tubercle- 
bacilli may be disseminated by the traumatism. Competent authors 
are arrayed on both sides of this question. Small lupoid patches 
certainly may be spread after resorting to most of the devices employed 
as remedial agents. 

The dermal curette is a sharp-edged spoon with or without a fenes- 
trum in the bowl to permit the escape of debris. By it the lupous 
growth may be completely scraped away, and, if necessary, caustics 
subsequently applied. Fox and others substitute the dental burr or 
dental excavator for the sharp spoon, though the change is not always 
for the better. Morris’s double parallel screw-excavator is an improve¬ 
ment on the common burr. Often it is well to supplement the action 
of the spoon or excavator with the flat electrode treatment of Jackson. 
Gartner and Lustgarten originally used as an electrode a flat silver 
plate attached to the negative pole of the battery, the plate being set in 
a hard-rubber ring. A current of from five to eight milliamperes 
is employed. 

The ablation of the entire lupous patch by the modern methods of 
surgery, followed by skin-grafting with the Thiersch method and its 
later substitutes may give good results, though in most cases Ihe 
lupous growth returns sooner or later in the new skin. The objections 
to it are chiefly that it involves the production of a larger and more 
conspicuous scar, since, as a rule, more tissue is removed by the knife 
than by the curette and its allies. 

The local treatment of lupus vulgaris by the aid of parasiticides is 
based upon the infectious character of the disease; and in many cases 
is brilliantly successful. White, 1 with a view to its parasitic action, 
applies to the lupous patches rags soaked in solutions of bichlorid of 


1 Boston Medical and Surgical Journal, October 29,1885. 


588 


DISEASES OF THE SKIN. 


mercury, 1 to 2 grains to the ounce (0.066-0.133 to 32.), and also 
applies ointments containing the same quantity of bichlorid in the 
ounce of salve-basis. The favorable results obtained by him have 
been also secured by freely painting lupous ulcers with a solution of 
corrosive sublimate in tincture of benzoin of the strength named. 
Salicylic acid, 2 to 4 per cent, solutions in castor oil, and in ointments 
J to 1 drachm to the ounce (2.-4. to 32.); sulphurous acid, or pyro- 
gallol in ointments of 10 per cent, to 50 per cent, strength, spread 
on linen rags, covered with impermeable tissue, and followed by the 
use of mercurial plaster and iodoform, have all been successfully 
employed with the same object in view. 

Decidedly inferior to these are the following methods, the first 
named, most popular in Germany; the second, in France; the third, 
to-day practically obsolete, and probably not to be revived. 

The Paquelin knife is extensively used in Vienna. The finer blades, 
especially manufactured for the purpose, are thrust, at a red heat, again 
and again through the lupous tissue until it is destroyed in its depth. 
Over the whole the lower blade is firmly passed and pressed, the black¬ 
ish coal resulting being the best subsequent dressing after the serous 
exudation ceases. Erasion is also followed by the galvano- or thermo¬ 
cautery. 

Multiple linear scarification, a modification of the Dubini- Volkmann 
method, was once claimed to have changed the prognoss of the disease. 
It is somewhat doubtful whether anything is to be gained by either a 
preliminary freezing of the part or the use of cutting-instruments of 
many blades. The incisions may be produced with a delicate bistoury 
held in the fingers like a pen. They should be in parallel lines, closely 
set together, and crossed; should extend completely through the depth 
of the lupous growth; and this is determinable after some practice by 
the cessation of the creaking resistance which the blade fails to discover 
in normal tissue. Further, these incisions should extend laterally 
beyond the borders of the lupous patch into the sound peripheral zone. 
The bleeding is trifling and readily arrested by firmly pressing small 
pieces of fine sponge, lint, or absorbent cotton over the part. The edges 
of the incision unite either by granulation or first intention; and in both 
cases seem to serve as starting-points of the reparative process, the 
material for which, as already pointed out, seems to be supplied from 
the lupous nests themselves. Subsequent operations, when needed, 
require a previous freezing of the affected surface. In France and in 
some portions of the British Empire this method is still popular. 

Treating by chemical cauterization alone is obsolete. The various 
acids and alkalies, particularly the hydrate of potash and lactic acid, 
Cosmos paste, nitrate of silver, arsenical, mercurial, and zinc com¬ 
pounds, and ethylate of sodium have all been employed thus, and 
in suitably selected cases have been in the past productive of fairly 
satisfactory results. 

With or without surgical interference, local applications may be 
employed, such as oily and fatty substances for the softening of crusts; 
stimulating dressings of tar, iodated glycerin, thymol, ichthyol, car- 
bolized glycerin, iodized phenol, naphtol, chrysarobin, and iodoform; 


NEW-GRO WTHS. 


589 


as also the carbolated unguents appropriate for the reparative j)hases 
of the ulcer left after the destruction of the lupous growth. 

Unna advocates the topical application of two parts of beech-tar 
creosote to one part of salicylic acid, the latter for its marked effect 
upon lupous tissue, and the former for what is supposed to be its 
anodyne effect in obtunding the pain produced by the action of the 
acid on the surface. That this explanation of the effect of the com¬ 
bination is not wholly correct is shown by the well-known fact that 
creosote alone is capable of producing a curative effect upon lupous 
tissue. In a former edition of this work, issued before the date of 
Unna’s experiments, creosote was set down as the dernier ressort of the 
physician in the topical management of lupus vulgaris. It can be 
used with the greatest advantage not only in severe cases by being 
brushed freely over the part, but in the combinations suggested by 
Unna. It will be found that when employed alone it is far from 
having at first the local effect of a “ morphine of the skin,” being 
productive, where no coca'in has been previously employed, of ex¬ 
quisite pain, which, however, is usually short-lived. It should be 
applied only with the greatest caution by the practitioner’s own hand, 
its effects watched and, if need be, counteracted, as in the local 
employment of hydrated potash. 

The application of fuchsin in 1 or 2 per cent, alcoholic solutions 
painted over the part, which has been previously scarified, is advocated 
by Fox and others. We have employed pykotanin blue in some cases 
with satisfactory results. 

The results of the injection of tuberculin (Koch’s lymph) in the 
treatment of lupus and scrofuloderma have been given to the scientific 
world in a mass of literature whose bulk has been scarcely equalled 
by that issued in connection with any other therapeutic measure. 
Whether it shall or shall not be revived in the future as an efficient 
means of treating tuberculosis of the skin is to-day uncertain. In 
some of the German hospitals the lymph is still injected, and, it is 
claimed, with a larger success than follows the older methods. In 
France, England, and America its use is practically abandoned. It 
has not been unattended with danger, and fatal results have in several 
instances been recorded after its injection. In other cases general 
tuberculosis has been induced; while in yet others the degree of im¬ 
provement following its employment has been inferior to that more 
readily reached by the curette and the topical use of mercury. 

The treatment of verruca necrogenica and other verrucous tubercu¬ 
loses of the skin is practically that of lupus vulgaris. The curette 
may be followed by one of the caustics advocated above, preferably 
by j)yrogallol, or a combination of salicylic acid and creosote. As a 
rule, mercurial lotions and salves are not well adapted to penetration 
of the warty or corneous envelope of the growth. 

The orificial lesions of tuberculosis cutis may, however, be well 
treated by these lotions, especially one in which \ to 2 per cent, of 
mercuric bichlorid is dissolved in compound tincture of benzoin or 
tolu. 

The local lesions of scrofuloderma may require the use of hot borated 


590 


DISEASES OF THE SKIN. 


lotions applied temporarily, or kept permanently in contact on com¬ 
presses covered by inpermeable tissue. The results of surgical abla¬ 
tion of enlarged lymphatic glands, broken down or threatening 
scrofulous “gummata,” and the complete disinfection and aseptic 
treatment to the point of cicatrization of the resulting wounds, furnish 
the most brilliant proofs of the real progress of modern surgery. 

In the local management of lichen scrofulosorum Hebra recom¬ 
mends the topical use of cod-liver oil smeared over the lesions, with 
woollen garments worn outside. At present medicated pastes are 
preferable. The local treatment of dermatoses of the scrofulous is, 
in fact, that indicated in each separate case. 

The prognosis of tuberculosis of the skin in all its manifestations is 
in the highest degree variable. Many patients affected with lupus 
vulgaris, even after the production of the severest grade of deformity, 
recover and without further local manifestations gain a degree of facial 
comeliness that is marvellous. The scrofulodermata in the same wav 
are remarkably improved, in the vast majority of all cases, by skilful 
medical and surgical management. In other cases systemic tubercu¬ 
losis develops after even a single tuberculous infection, and grave 
results may occur either early in life or even after years of tuberculous 
involvement of the skin and other organs. Other things equal, the 
prognosis in tuberculosis of the skin, as compared with that of other 
organs, is relatively favorable, due to the sparsity of the tubercle-bacilli 
in most cutaneous lesions, the skin being exposed too largely to exter¬ 
nal influences to form a good field for development of new colonies of 
bacilli. Any form of tuberculosis of the skin, however, may result in 
systemic infection and death. 


LUPUS ERYTHEMATOSUS 

(Lat. lupus, a wolf.) 

(Lupus Sebaceus, Lupus Superficialis, “Scrofulous Ring¬ 
worm/’ Seborrhea Congestiva, Lupus Erythematodes, 
Lupus Non-exedens, Ulerythema Centrifugum. Fr. y 
Scrofulide Eryth£mateuse, Erytheme Centrifuge. ; 

Statistical frequency in America, 0.385. 

Lupus erythematosus is a cutaneous‘new-growth, displayed in well-defined, slightly 
raised, discoid patches, often with a depressed or atrophied centre colored in vari¬ 
ous shades of hyperemia, covered with adherent, yellowish-gray scales, and termi¬ 
nating, after a favorable involution, by the production of a persistent scar. 

This disease was first described by Biett under the title Erytheme 
Centrifuge. Hebra, in 1845, described it among the seborrheas, as 
Seborrhea Congestiva. Its present title was given by Cazenave in 
1850. 

Symptoms. The disease is first exhibited in one or several rape-seed- 
to bean-sized, reddish macules, slightly elevated from the surface, and 
covered with a peculiar glistening epidermis or with an adherent scale. 


NEW-GROWTHS. 


591 


When bat a single patch is formed the primary lesion described above 
enlarges its periphery, in the course of months or years, by a slowly 
continuous development. Its reddish outer rim is then distinctly ele¬ 
vated, while its centre is depressed, showing either adherent, yellowish- 
gray scales, or a glistening appearance of the unbroken epidermis. It 
may thus attain the size of a small coin or a large saucer, and occur 
in this form symmetrically or asymmetrically about the cheeks, nose, 
eyelids, forehead, arms, scalp, mouth, hands, and feet. The disks or 
patches are very well defined in outline, and of a color varying with 
the complexion of the patient, from a rosy-pinkish to a deep purplish 
hue. The shape is usually circular, oval, or in figures representing 
combinations of these outlines. The scales, too, vary in color, being 
at times of a clear white or whitish-yellow, and, again, often from 
concurrence of comedones, of a leaden or brownish tint. The latter 
are usually scanty and adherent, but are also, rarely, abundant. They 
can be occasionally seen firmly fastened to the orifice of the excretory 
duct of a sebaceous gland. When such a patch spreads symmetrically 
over the brow and cheeks its figure has been likened by Hebra to the 
open wings of a butterfly. 

When the macules originate as multiple lesions the evolution of the 
disease may be accomplished by increase in the number of the former, 
rather than, as just described, by the peripheral extension of a single 
patch. The disease is then apt to be manifested, not only in the regions 
named above, but over the trunk and extremities, where it is likely to 
assume atypical forms, and be complicated by accesses of a febrile or 
neuralgic character, and by various cutaneous accidents, such as erysip¬ 
elas, dermatitis, etc. 

The several forms of lupus erythematosus are differently classified 
by observers. They are in most cases distiuguished chiefly by these 
clinical features: 

( a ) The telangiectatic form. Here points, spots, plaques, or large 
disks of the surface, chiefly of the face, usually well defined, present 
a rosy-reddish, deep-purplish, or yellowish color, which disappears 
under pressure. When examined with care the color is seen to be due 
to dilatation of the cutaneous vessels. The surface may be then either 
slightly oedematous or infiltrated, and to a slight degree elevated. The 
epithelial surface exposed to the eye may be smooth, shining, and dry; 
or covered with scales, either dry or fatty, sometimes adhering firmly 
to the excretory orifices of the ducts of the sebaceous glands. The 
centre of the plaque or coin-sized or larger disk is commonly flattened 
or depressed, and in the course of the disorder either returns to the 
normal condition of the skin or leaves a characteristic dotted or 
stippled cicatrix. 

Several subvarieties of this form may be recognized. In the sim¬ 
plest the lesions described above appear with or without marked sym¬ 
metry over the scalp, face, ears, and other organs, with either dry or 
fatty scales on the surface of the disks, slowly progressing to an extreme 
development, and, when occurring upon the scalp, removing the hairs 
somewhat as in alopecia areata. 

An exanthematic variety occurs in both circumscribed and general- 


592 


DISEASES OF THE SKIN. 


ized lesions. In the former the symmetry is well marked, and the 
eruptive symptoms occur with subacute, intermittent, or remittent 
development. Some of the patches resolve without leaving trace of 
their existence; others leave the persistent and indelible cicatrices seen 
in more typical cases. The reddened plaques are, by several authors, 
likened to the lesions of exudative erythema, being hot to the touch, 
tender, raised, and manifestly centrifugal in their mode of extension. 
The erythematous aspect of the eruptive symptoms is highly charac¬ 
teristic. Here, as in other forms of the disease, the appearance of the 
bat’s wing in the disks, on either side of the nose, with a strip along 
the bridge, may be well marked. 

The generalized lesions also may disappear without leaving traces of 
their existence, or may also leave characteristic thin, white scars. As 
a rule, the lesions first appear on the face, but later they develop on 
any part of the body, and usually large surfaces are involved. At 
times the subjective sensations are severe (itching, burning, heat, etc.), 
and the patches may even be the seat of vesicles, pustules, or bullse 
which eventually accomplish crusting, the parts beneath the crusts 
showing characteristic patulous orifices of the ducts of the sebaceous 
glands (Lupus Disseminatus, Lupus Iris). As in erythema multi¬ 
forme, there may be in these cases coincident febrile symptoms, erysip¬ 
elatous changes, and involvement of the joints and bones. In rare 
cases there are malignant symptoms, the patient soon dying of maras¬ 
mus, tuberculosis, anemia, or grave renal disease. Here the skin lesions 
are manifestly merely surface-symptoms of a general process. Here, 
also, are to be classed the forms upon which French and other authors 
base their convictions that lupus erythematosus is one of the manifes¬ 
tations of what was once known as “ scrofula.” That the disease may 
be at times one of the dermatoses of the scrofulous has been already 
shown in the chapter on Cutaneous Tuberculosis. 

One of the interesting forms of this class of lesions is exhibited on 
the fingers and toes particularly, but also on other parts of the hands 
and feet , 1 beginning as a more or less persistent erythema of the type of 
pernio (chilblain), often scaling and resolving, as noted in the other cases 
of this type, either without or with characteristic scarring. In some 
cases the verrucous aspect of the patch on the hands is well marked, 
the thickened epidermis rising to a marked degree above the general 
level, with a reddish or purplish border about the periphery. Fissures 
may complicate this condition; often when the hands are used in man¬ 
ual labor the soreness is a marked feature of the disease. 

A last subvariety is recognized on the face, hands, and other regions, 
where the symptoms present the characters of local asphyxia (digiti 
mortai). Here the influence of the trophic nerves, as in other condi¬ 
tions with similar symptoms, is distinct. The disease begins with the 
appearance of livid spots in the regions named, which persist for 
months or even years, and eventually degenerate at the centre, leaving 
a slough, beneath which lies an ulcer. In these cases, also, tubercu¬ 
lous complications occur in the joints. 

‘ Cf. contributions to this subject by the author, Journal of Cutaneous and Venereal Diseases, 
1884, vol. n.; and by Ohmann-Dumesnil, Ninth International Medical Congress, 1887. 


NEW-GROWTHS. 


593 


(b) The follicular variety. In this form the hyperemic or telangiec¬ 
tatic symptoms are less apparent. The eruptive lesions are usually in 
discrete or confluent points, disks, or plaques, with definite borders, 
and covered with dry, whitish, or whitish and grayish scales or a scaly 
pellicle, firmly adherent, and obviously attached at the orifices of the 
sebaceous glands. This is the common type of lupus erythematosus, 
and is seen on the scalp; the tip, bridge, and alse of the nose; the 
circumorbital regions; the lips; cheeks; and all portions of the surface. 
In some cases the erythematous redness, in others the crusted surface of 
the disk, is the more pronounced feature. The outlying area of each 
disk may be crusted, reddened, or pigmented. As a rule, the redness 
fades centrally and increases at the periphery, where the surface is 


Fig. 71. 



Lupus erythematosus of the face (from a photograph). 


slightly elevated as distinguished from the depressed or more rarely 
level centre. Often the surface of the patch is very irregular, scale- 
covered, the spots of adherent scales being distinctly circumscribed 
within the general enclosing area of the disk. The characteristic thin 
white scar left by the disease may appear centrally when the morbid 
process is in activity at the border, but usually in the latter even the rim 
is simply made up of a reddish ring covered with firmly attached scales. 

Mixed forms occur where all the symptoms described above may coin- 
cidently or successively appear in one subject. Variations are marked 
in both the vascular and follicular directions. In the latter there are 
seen at times patches exhibiting almost pure types of seborrhea faciei. 

The disease is remarkably chronic in its course, lasting in cases for 

38 




594 


DISEASES OF THE SKIN\ 


a quarter of a century, and throughout not interfering with the general 
health. So-called “ galloping ’’ cases are described by French writers 
usually with the visceral complications described above. The disease 
varies in the subjective sensations it produces; being at times accom¬ 
panied by excessive itching and often by no discomfort. It is more 
common in women than in men, and is a disease of adult years. 
Kaposi reports a single case in a child three years of age. 

The scars left by the affection are indelible and characteristic. They 
are generally uniform and superficial; can be readily pinched up be¬ 
tween the thumb and finger; are of a dull, whitish tint, and rendered 
punctate in a peculiar manner, suggesting the action of the engraver s 
tool in what is known as the “ stippling” process. They are never 
pigmented, puckered, radiate, stellate, corded, or deeply attached. 
Very rarely they are seated upon the glans penis. 

Etiology . Lupus erythematosus is described by some writers as a 
variety of lupus vulgaris. It is, however, not properly so classed until 
tubercle-bacilli have been recognized in its lesions, a position not yet 
fully reached. Its causes are as yet obscure. 

Much has been said and written to prove that the disease is of tuber¬ 
culous origin, but inasmuch as numbers of tuberculous patients in all 
parts of the world never exhibit traces of the disease, the proof has 
not been obtained. In by far the larger number of patients actually 
displaying characteristic disks of erythematous lupus the usual con¬ 
comitants of tuberculosis are wanting. In many patients careful 
investigation fails to discover any other evidence of ill health. Yet 
others, chiefly young women after the puberal epoch, suffer from the 
chlorosis, anemia, and menstrual irregularities common to their sex 
and age. As for tuberculosis, adenopathy, and malnutrition, cases of 
erythematous lupus do occur in subjects affected with such symptoms, 
as has been shown. Besnier claims that severe forms of general 
tuberculosis are associated very frequently with lupus erythematosus, 
more frequently than with lupus vulgaris, and thinks there are strong 
clinical grounds for believing the disease to be a form of tuberculosis. 
Considering the rarity of the disease and the no less significant fre¬ 
quency of seborrhea, the wonder is not that they should occasionally 
concur, or be transformed the latter into the former, but that such 
phenomena are not more conspicuously and frequently noted. 

The disease is more common in women than in men, two-thirds of the 
former to one of the latter, and usually appears first in the third decade 
of life, in this particular presenting a contrast with lupus vulgaris. 
It may, however, first develop in childhood, middle life, or old age. 

Lupus erythematosus may follow acne, undue exposure to sunlight, 
seborrhea, variola, erysipelas, vesication with cantharides, or the trau¬ 
matism of leech-bites. It mav appear where the curette has been 
employed in a patient with a characteristic patch elsewhere on the 
face. It occasionally develops on portions of the face and hands that 
have been subject to recurrent attacks of pernio. 

Pathology. Although the pathology of lupus erythematosus has 
been studied by a number of observers, it is not yet well understood. 
The chief changes are found in the upper half or third of the corium 


iVEW-GROWTHS. 


595 


in the form of a dense infiltration of small round cells of an embryonic 
type, a small proportion of which are probably the result of prolifera¬ 
tion of the fixed cells of the part. The infiltration varies greatly in 
extent and in density in different types of lesions, but is most pro¬ 
nounced along the course of the vessels. It is often found in slight 
degree in the deeper parts of the corium and subcutaneous tissue; but 
it nowhere forms nodules as in lupus vulgaris; there are no giant cells; 
and there is no degeneration of a mass of cells as in the latter disease. 
Individual cells here and there undergo a granular and fatty or colloid 
degeneration, disappear by absorption, and are replaced by new cells. 
The connective-tissue fibres are destroyed in the same way. Many of 
the vessels are seen to be greatly distended and choked with red blood- 
corpuscles, others show a proliferation of their walls and in some cases 
an obliterating endarteritis. Diffuse or localized hemorrhages are 
found in the upper part of the cutis. By some observers the vascular 
changes are considered primary in the process. The sebaceous glands 
are at first hypertrophied, affected with hypersecretion, and become 
filled with cells and abnormal sebaceous matter. Later both they and 
the ducts of the coil-glands may become infiltrated, undergo degenera¬ 
tion and disappear, leaving the peculiarly punctate form of scar 
characteristic of the disease. 

The epidermal layers become atrophied, and the interpapillary 
depressions of the rete as well as the papillae are largely obliterated. 

The cause of the process is not known, no pathogenic micro-organism 
has been found, and inoculation-experiments have not been successful. 

Diagnosis. The facies of the patient with lupus erythematosus of 
that region is usually so characteristic that the disease is there recog¬ 
nized with ease. When the hand and other portions of the body are 
involved the diagnosis is somewhat less readily established. In the 
former situation the disease has a predilection for the dorsum, and 
invades the palm usually only by extension to it from behind. 

From lupus vulgaris erythematous lupus may be recognized by its 
occurrence originally at a later period of life ; by its greater tendency 
to symmetry; and by the absence in most cases of nodules, ulceration, 
and extension to the deeper portions of the skin or underlying struc¬ 
tures. Cases undoubtedly do occur in which the diagnosis is very dif¬ 
ficult, as in the type called by Leloir lupus vulgaris erythematoide. But 
as in all cases of lupus vulgaris typical nodules appear sooner or later, 
the diagnosis can eventually be established. 

In eczema there is usually some history of moisture; in erythema¬ 
tous lupus, rarely. In eczema, also, the itching is a more persistent 
and distressing symptom; but the acuteness of even chronic eczema, 
as compared with lupus erythematosus, will suffice to distinguish the 
two diseases. Psoriasis is rarely, if ever, limited to a single patch on 
the face; it is also characterized by more lustrous and more readily 
exfoliating scales. Its patches are, furthermore, uniformly well cov¬ 
ered with scales, and of equal flatness in all parts, while those of lupus 
erythematosus are irregularly squamous, the scales being often clustered 
at the orifices of the ducts of the sebaceous glands, while the rim of 
the patch is elevated and the centre depressed. From pernio the 
diagnosis can sometimes only be made after watching the case to see if 


596 


DISEASES OF THE SKIN. 


the lesions disappear during the warm season, as in pernio; or persist, 
as in lupus erythematosus. 

In acne rosacea there are marked telangiectases and papulo-pustules 
or nodules which are not found in erythematous lupus. In tinea cir- 
cinata there may be a clearing, but never a cicatriform centre of the 
circular disk. The circular serpiginous syphilodermata of the face 
occur usually with other manifestations of lues, are characterized by a 
much darker hue of the dense infiltration, and in most cases exhibit 
distinct signs of ulceration. Cicatrization or atrophy of the skin without 
preceding ulceration is the sign and seal of typical erythematous lupus. 

Ireatment. The internal treatment of this affection is not highly 
satisfactory. Often none is indicated or required. Anderson 1 highly 
recommends the trituration of 24 grains (1.6) of iodin with a little 
water, adding to this 1 ounce (32) of starch, till a uniform deep blue, 
almost black color is obtained, after which the iodid is dried by gentle 
heat. A large teaspoonful is given in a little gruel three times daily. 
The administration of the iodid of potassium, arsenic, and iodoform 
has also been followed by noteworthy results. In general, however, 
cod-liver oil and the chalybeates will be found most serviceable in 
connection with such hygienic regimen and diet as are in each case 
specially indicated. 

The local treatment of the patches of disease is of importance. Inas¬ 
much as the affection is one the involution of which is occasionally 
accomplished under the influence of mild topical applications, and is 
succeeded very rarely by grave sequels, the simpler measures should 
be first adopted. Of these, green soap, applied as a plaster or in the 
form of the spiritus saponis viridis, is most serviceable. It not only 
cleanses the patch of its scales, but stimulates the surface, often to the 
extent of inducing a reparative process. The patch may be briskly 
rubbed, either with soap or the spirit, in combination with hot water, 
after which an ointment may be applied, preferably of sulphur, in the 
strength of 2 drachms (8.) to the ounce (32.) of petroleum ointment. 
When decided irritation of the part is produced the spirit may be dis¬ 
continued, and the hot water and unguent for a time employed alone. 
A decided and beneficial effect can be noticed occasionally after the 
topical application of very hot water alone, sopped on the part for 
twenty minutes at a time with a small sponge mounted on a handle. 

The following is a gentle stimulant: 


M —Zinci sulphat., 1 .. - . 

Potassii sulphuret., j aa 3 SS > 

Spts. vin. rectif., fT, iij ; 

Aq. rosar., f^iijss; 

Sig.—To be diluted as required for external use. 


The following is a formula for a stronger lotion: 


M —Chrysarobin , 

Acid, salicylici, \ 

Calaminis pulv , f 
AStheris 
Collodii flex., 

Sig —To be applied with a brush 


Z yss; 
aa ss; 

*5j; 

f3v; 


2 

12 

112 


M 


[Duhring.] 


10 


4 

20 M 


1 British Medical Journal, May, 1880. 



NEW-GROWTHS. 


597 


For this may he substituted pyrogallol, in the strength of \ drachm 
(2.) to the ounce (32.) of salve. 

Other substances for local application are: the tars, iodized phenol, 
iodized glycerin, iodid of sulphur, iodid of potassium, iodin in fine 
powder and tincture, naphtol, ichthyol, chloracetic acid, salicylic acid 
3 to 10 per cent., and resorcin 10 per cent., each in collodion; and 
sodium ethylate (an unsatisfactory preparation). Thilanin, lately 
recommended with some reserve by Fox, of New York, has been 
employed in a few cases with success. Chrysarobin and pyrogallol 
have a decidedly favorable effect, subject, however, to the inconve¬ 
nience of staining the skin, a prominent objection in the majority of 
cases where the disease is displayed upon the face. 

The non-vascularized, indolent, and superficial varieties of erythe¬ 
matous lupus are often treated with very satisfactory results by the 
topical application of a saturated solution of pyoktanin blue. This 
method has the great disadvantage of producing a deep bluish stain of 
the face, but the disfigurement is willingly tolerated for a brief period 
by patients who have long suffered from the facial unsightliness of 
the disease itself. The solution is thickly painted daily over the 
entire portion affected; and the application usually may be made by 
an unskilled hand No pain is produced and no untoward effect of 
any kind has yet been noted. The applications have been repeated 
continuously for sixty days and more with excellent results. A 
somewhat similar effect, when the lupous patches begin to lose their 
characteristic scale and color, is apparent in a vitiligoid bleaching of 
the skin, surrounded occasionally at its border by a hyperpigmentation 
of the integument. 

Erasion by the dermal curette, in accordance with the method pro¬ 
posed by Dubini, of Milan, and popularized by Volkmann, of Halle, 
has been successfully practised by many operators; as also treatment 
by multiple punctures. These have not met with the favor in lupus 
erythematosus which has been accorded them in lupus vulgaris; while 
multiple incisions by the lancet, or the instrument devised by Bal- 
manno Squire 1 have been rewarded with greater success. Squire’s 
instrument makes sixteen simultaneous superficial incisions in the 
patch previously frozen by the ether spray. Vidal 2 lays stress upon 
attacking in this way the peripheral zone of the lesions. 

In exceedingly obstinate cases, those especially where the elevated rim 
of the erythematous disk refuses to yield to the simple measures de¬ 
scribed, a solution of caustic potassium in distilled water, one part to 
two or four, may be gently applied with a camel’s-hair brush, and the 
alkali immediately neutralized by the addition of dilute muriatic acid 
as soon as the desired effect is produced. That effect, it must be 
remembered, is superficial cauterization only. When the sero-sanguin- 
eous exudation and reactive effects disappear the rim is seen to be 
flattened and to have lost in part its violaceous blush, .After such 
severe application, which should never be trusted to the hand of one 
unskilled in its use, an anodyne cerate containing morphin or opium 
should be spread over the part. 


1 British Medical Journal, May, 1880. 


2 Le Praticien, November 14,1881. 


598 


DISEASES OF THE SKIN. 


Vesication with cantharides, recommended by Anderson, has been 
endorsed as valuable by several authors. The same may be said of 
mercurial plaster, of which Kaposi speaks highly; while he and others 
agree that carbolic, salicylic, nitric, chromic, and sulphuric acids, 
chlorid of zinc, mercurial preparations, and arsenical pastes are of 
less value. 

Electrolysis is of benefit in a few cases, the needle connected with 
the negative pole of the battery being passed deeply into the involved 
tissue. Among other useful applications may be named pure creo¬ 
sote, white precipitate salve, Unna’s gutta-percha plaster-mulls of pyro- 
gallol, iodoform, and zinc oxid pastes. 

Prognosis. A favorable opinion with respect to the future of the 
disease can never be safely given; though, as regards the general health 
and comfort of the patient, there can rarely be question. At the same 
time the affection is capricious in its course, and may on occasions, after 
long periods of obstinate persistence, very rapidly improve under the 
simplest treatment. It is liable to relapse, though not to frequent 
recurrence. Its tendency to the production of persistent scars should 
always be remembered in formulating a diagnosis. 


AINHUM. 

(From a native term, meaning “to saw.”) 

This disease was first described by Dr. J. F. Da Silva Lima, of Bahia, 
in Brazil. In a paper by this observer, which was read by me before 
the American Dermatological Association, in 1880, the disease was 
described as affecting usually the little toe of negroes resident both in 
Africa and Brazil. An indurated ring encircled the root of the digit, 
which produced, finally, a deep, narrow circular depression, the latter 
deepening till the toe was strangulated, and finally, in the course of 
from five to ten years, completely detached. Meantime the volume 
of the digit was greatly increased by development of fatty tissue at 
the expense of the tendons, vascular elements, bones, and cartilages. 

This paper was accompanied by the presentation of a toe affected 
with ainhum; and the specimen was referred to a committee, who 
examined it with care, and reported the result of the examination the 
succeeding year. The report, presented by Dr. Heitzmann, of Xew 
York, after giving a full description of the anatomical appearance of 
the specimen, suggested the probability that the constricting ring was 
produced artificially by tying a thin ligature around the toe, which, if 
not continuously encircling it, was worn at least for long periods of time. 

Duhring also has published the report of a case of ainhum where 
microscopical examination was made by Dr. Wile of a toe which was 
cast off from the foot of a negro in West Virginia. The pathologist 
came to the conclusion in this case also that the disease was essentially 
an inflammatory oedema produced by ligating the toe. 

Later, Roux 1 and Rouget 2 with Trelat, Eyles, and others have 
further studied this disorder. None seems vet to have disproved the 


1 Traite prat, des Malad. des Pays Chauds, t. iii., Paris, 1888. 


2 These de Paris, 1889. 


NEW-GROWTHS. 


599 


fact that among superstitious races, eSj ecially the blacks, the most 
singular practices of self-mutilation are observed; and the enormous 
probability that in these cases the toe is constricted by a ligature inten¬ 
tionally applied around it, has not yet been set aside. 

It is a fact, however, that a constricting ring may encircle a digit 
and endanger its integrity when the constriction is a result of disease 
wholly unconnected with any attempts at ligating the part. This fact 
was well illustrated by a child lately presented at the clinic, a deaf 
mute who was an inmate of one of the public institutions founded for 
the care of that class of sufferers. The patient was twelve years of 
age, fairly well nourished, and the subject of a symmetrical palmar 
and plantar keratosis. The little finger of each hand in the middle 
of the proximal phalanx was closely encircled by a tensely drawn 
cicatriform linear girdle, the constriction of which was rapidly work¬ 
ing an amputation of the little finger of the left hand, the right being 
less seriously involved, and some other fingers incompletely girdled by 
constrictions existing only on the palmar faces. Here the demonstration 
of the cause was clearly made, for the callous ring about the digits was 
manifestly in line with the equally dense callosities of the palms and 
soles, which differed from the former chiefly because of their occurrence 
in broad plates rather than in narrow lines. 

The affection is described as a special disease of the toes, noticeably 
never congenital nor affecting any but adults. 

Ainhum would seem to have no relation with sclerodactylie, sclero¬ 
derma, nor to spontaneous amputation of members due to mutilating 
disease. The histological evidence, in the many cases examined, dis¬ 
closes no process save that producible by constriction; rarefying 
osteitis, hyperplasia of the skiu and all other tissues in advance of 
the constricting ring, endarteritis obliterans, and gradually resulting 
fatty metamorphosis. 

Incision of the constricting ring at an early period is said to relieve 
the disease. In most of the cases amputation is required or is effected 
by the natural progress of the disorder. 


SYPHILODERMA. 

(Gr. ovc and 0/Aof, a companion of swine: a term coined for poetical 
purposes by Fracastor.) 

Statistical frequency in America, 11.22. 

Syphilis is a chronic infectious disease transmitted by heredity, or by the medium 
of intoxicated blood or of morbid secretions, and capable of involving in its course 
any one of the organs and tissues of the body, whose manifestations in the skin 
are termed “ syphilodermata ” 

Syphilis is a disease not yet actually demonstrated as being produced 
by micro-organisms, but its position among the infectious granulomata 
is now practically established. It is true that Lustgarten, Doutrele- 
pont, and others have demonstrated the presence of bacilli (resembling 
those found in tubercle) in papules, nodes, chancres, and secretions 
from syphilitic lesions; but the strict requirements of science as to the 


600 


DISEASES OF THE SKIN. 


proofs of etiological value for these particular germs have not yet fully 
been satisfied with respect to this disease. Whether these micro¬ 
organisms or others are finally demonstrated to be the potent agency in 
producing svpliilis when it is transmitted by the medium of a virus, 
it is at least certain that the revelations made by late investigations 
into the nature of lepra and tuberculosis lend the very strongest sup¬ 
port to the doctrine that the contagium of syphilis is due to the pres¬ 
ence in its secretions of a species of bacterium. 

Syphilis has been described by one writer as an “ imitator of other 
diseases.” The manifestations of the malady are certainly protean 
in character, and they may occur in every organ and tissue of the 
body. These phenomena are both like and unlike the symptoms 
of non-syphilitic disease of such organs and tissues. It would, there¬ 
fore, be more in accordance with facts to describe syphilis as a special 
mode of disease. Its phenomena differ from other pathological phe¬ 
nomena chiefly in the syphilitic modality with which they are im¬ 
pressed. After infection there is a different behavior of the living 
matter or protoplasm of which the body is constituted. Its mode 
thenceforward is temporarily changed as regards the process of disease. 
Hence the importance of recognizing this modality in relation to disease 
of the skin, and of ascertaining the limits within which this influence 
is both originated and exhausted. 

Ricord, of France, was first to classify the phenomena of syphilis as 
they develop into three distinct stages. In the first stage, or primary 
syphilis, were included symptoms relating to the chancre and its accom¬ 
panying adenopathy. In the second stage, lasting from the date of 
the onset of general syphilis during a period of about two years, were 
grouped symptoms that were, as a rule, superficial, symmetrical, and 
more or less transitory. In the third, or tertiary stage, the symptoms 
included were, as a rule, asymmetrical, more profound, involving the 
subcutaneous and deeper tissues, and invading often not merely the 
skin, but also the osseous, cartilaginous, and other structures of the 
body, including the viscera. This simple scheme of the great syphilog- 
rapher when first given to the scientific world revolutionized all pre 
vious conceptions of the disease, and has dominated the medical 
profession up to the present time. 

But there are objections to continued acceptance of this scheme, based 
largely on its incompleteness. The distinctions it seeks to make are 
wholly artificial, are defined bv poor limits, and are so often completely 
violated that they fail to explain the most important of accidents. To 
be consistent and to explain in part the violations of their time-sched¬ 
ule, the French have coined such phrases as “ precoc’ous,” “ tardy ,’ 9 
“galloping,” etc. Further, the mind once dominated by this scheme 
was educated to look for the evolution of symptoms within each of 
these artificial stages in a determinate order, e. g., after the occurrence 
of macules, succeeded papules; after these, pustules, tubercles, etc., a 
progression rarely observed in any given case. 

The symptoms of syphilis are better studied, as they are clinically 
displayed in distinct departures from the infection-moment, along lines 
which are not fixed, but where symptoms are intermingled with varying 


NEW-GROWTHS. 


601 


shades of severity. The four chief classes which may thus be recog¬ 
nized include most of the clinical pictures of syphilis: 

I. Benignant Syphilis , with Superficial and Transitory Symptoms. 
In this first class the skin-lesions of general syphilis are few and at 
times are even insignificant. A macular rash, for example, over the 
surface of the chest and belly, lasting for a few days or for a week 
or more, accompanied by ganglionic enlargement, after involution, 
leaves the patient for the remainder of life free from obvious signs of 
the malady. These instances are rare. 

II. Benignant Syphilis, with Superficial and more or less Persistent 
Symptoms. In this class are to be catalogued most cases of the disease. 
Some cases relapse to it from the class previously described; others, 
fewer in number, retrograde to one of the groups named below. There 
is throughout no cachexia, and the skin symptoms of the affection are 
neither destructive nor deep. Their chief significance lies in the fact 
that they may persist or may recur until the disease, either as a result 
of treatment or of a decline due to other causes, ceases to manifest 
itself by any symptoms whatever. 

III. Malignant Syphilis , with Profound, Relapsing, or Persistent 
Symptoms that Ultimately Resolve. In this group are collected those 
cases in which, with persistent or with recurrent symptoms gradually 
involving the deeper structures of the body, the system suffers to the 
extent of exhibiting the signs of cachexia. Patients in this class, by 
reason of efficient treatment or the reverse, are readily transferred both 
to the second class and to the fourth. 

IV. Malignant Syphilis, with Profound and Relapsing or Persistent 
Symptoms that are Ultimately Destructive. In this class are included 
the gravest forms of the disease; those exhibiting deep aud destruc¬ 
tive cutaneous lesions; those implicating the viscera, bones, and other 
structures; those interfering with the integrity of the organs by reason 
of either atrophic or degenerative changes succeeding a circumscribed 
or gummatous involvement of tissue. 

Vo one of the groups of symptoms named above necessarily follows 
any other. The last-described group may occur within a few months 
after the appearance of so-called u primary syphilis,” even though 
formerly included in the old nomenclature among those of late, or 
tertiary type. Many cases, indeed, of grave syphilis are of the type 
described by the French as “ precocious,” that is, they develop symp¬ 
toms of gravity either before or soon after the healing of the chancre. 

Every attack of acquired syphilis acknowledges as its first symptom 
an infecting chancre, and every infecting chancre signifies syphilis. 

Chancre. A chancre is that modification of the sound or the path¬ 
ologically altered skin or mucous membrane, preceded by a period of 
incubation, characterized by sclerosis, and accompanied by adenopathy, 
which constitutes the initial lesion of inevitable syphilis. 

Chancres usually appear upon or about the genital organs simply be¬ 
cause these organs are most often exposed to the disease. These lesions 
may, however, occur upon any portion of the surface of the body. 


602 


DISEASES OF THE SKIN. 


Chancres appear after a period of incubation—an interval of time 
between the date of exposure to the disease and the manifestation of 
its first symptom. This period averages twenty-one days, but it may 
extend from ten days to two months and even more. 

The chancrous modification may involve, as stated above, the normal 
or the pathologically altered skin or mucous membrane. Upon 
previously sound surfaces chancres may appear, after an incubative 
period, as macules, papules, tubercles, erosions, fissures, or ulcers, each 
or either of which, at some future period of its history, is character¬ 
ized by a peculiar hardness of the tissues about and beneath the lesion, 
this condition being known as the “ initial sclerosis.” These symp¬ 
toms vary according to the location of the chancre and the friction or 
other external treatment to which the lesion has accidentally been sub¬ 
jected. Generally it may be said that all chancres tend to conform to 
the papular type, the macule developing into the chancrous lesion, the 
tubercle being evolved from its exceptional enlargement, the ulcer'from 
its degeneration, and the erosions or fissures from the accidents of its 
less pronounced features. Occurring upon mucous or quasi-mucous 
surfaces these lesions are influenced by heat, moisture, and friction 
(labia, prepuce, etc.). Here the superficial erosions are usually circular 
in outline, are very slightly depressed, and they rest upon delicate beds 
of sclerosed tissue, the so-called u parchment-induration.” The pap¬ 
ule is often represented by a tolerably well-circumscribed, macular 
discoloration of the membrane, where coarse examination would 
scarcely suggest elevation of the surface, with a sclerosis of no greater 
extent than that of the erosion, with which it probably sustains a close 
relation. As a result of heat, moisture, and friction, however, the 
typically dry and scaling papule constituting the chancre of the integ¬ 
ument, is here rarely encountered. More often the lesion is a circum¬ 
scribed ulcer with clean-cut walls, penetrating deeply to the derma or 
even below, with a scanty secretion and a reddish floor, resting upon 
a split-pea-sized mass of sclerosed tissue. Other usual forms are 
superficial erosions, in themselves of insignificant aspect, surmounting 
large nodules, tubercles, or even loug linear ridges of deusely sclerosed 
tissue, undergoing repair or degenerating according to the condition of 
the patient and the treatment to which he has been subjected. These 
erosions are usually out of proportion to the size of the indurated mass 
upon which they rest. Such voluminous indurations are occasionally 
perforated by deep conical or funnel-shaped ulcerations of formidable 
aspect, to which the name “ Hunterian chancre” was once applied. 

Occurring upon cutaneous or mucous surfaces, where there has been 
a previous morbid process, the syphilitic mode is impressed upon 
the symptoms significant of such antecedent disease. This accident is 
sufficiently common, and the resulting lesions are as different as are 
those of different diseases. Thus, a man or woman may be infected with 
syphilis at the site of an herpetic vesicle upon the lip or the genitals, 
such vesicle being unbroken and recent, or several days ruptured; or 
at the site of a balanitis; or of a vegetation; or of the soft contagious 
sore of the genital region best recognized in America under the 
term (( chancroid.” Or the inoculation may occur at the site of a 


NEW-GROWTHS. 


603 


traumatism, for example, where the frenum is slightly torn in coitus, 
or where the bruised knuckle of the accoucheur is exposed during the 
practice of his art. 

The induration of chancres may precede, accompany, or follow the 
lesion with which they are associated. The sclerosis may be short¬ 
lived, persistent, or recurrent, and in this respect may resemble the 
chancre itself, which may endure but for a few days, or be in course 
of full evolution at the date of appearance of the so-called “ second¬ 
ary” symptoms. 

As a consequence, the gauglia in anatomical connection with the 
chancre become, with very rare exceptions, enlarged and specifically 
indurated. With genital chancres there is usually double inguinal 
adenopathy; with labial chancres, submaxillary adenopathy; with chan¬ 
cres of the eyelid, pre-auricular adenopathy, etc. The glands usually 
enlarge within a few days after the appearance of the chancre, and 
remain in that condition for several months. They are indurated on 
one or on both sides of the body; are freely movable; are unattached 
to surrounding tissues; are neither painful, tender, nor inflammatory, 
and they therefore terminate neither by suppuration nor by ulceration. 
It will thus be evident that the word u chancre ” is applicable only to 
certain features assumed by other lesions, and is not itself descriptive 
of a lesion differing absolutely from all others. It is indeed clear that 
there can be no particular chancre-lesion, since in turn the macule, 
vesicle, pustule, papule, tubercle, erosion, vegetation, ulcer, and fissure 
may each become a chancre. Every other elementary lesion of the 
skin, therefore, may assume the chancrous features; in other words, 
may display in its disease-process the modality of syphilis. These 
chancrous features are: infection; sclerosis after an incubative period; 
coincident or consequent adenopathy (sclerosis of neighboring ganglia); 
and, after a second incubative period, the occurrence of the symptoms 
of general syphilis. The last-named is, of course, an historical feature, 
not recognizable during the greater part of the life of most chancres. 

The minor chancrous features are less constant and trustworthy. 
Chancres of the skin are often deeply pigmented. Some are painful 
from the occurrence of inflammation; some are injured by traumatism 
(chancres of the nipple in nursing-women); some, by irritants (caustic 
improperly applied); some, finally, are so insignificant in feature 
(chancre of the vagina) that even the expert is readily deceived in 
their recognition. 

With or without involution and complete disappearance of the 
chancre, the symptoms of general syphilis occur only after a so-called 
“ second period of incubation.” This period extends usually from 
between the end of the first to the end of the second month after the 
appearance of the chancre, the average being between the fortieth and 
the forty-fifth day. During this period the general condition of the 
patient is that which, by subjective and objective phenomena, displays 
signals of the approaching distress of the economy. There is anemia, 
and, in cases, even chloro-anemia; wandering pains, substernal or about 
the articulations; a cachectic look; engorgement of the superficial and 
deep ganglia; occasionally a well-marked febrile process, the so-called 


604 


DISEASES OF THE SKIN. 


“ syphilitic fever;” and, as Bumstead has shown, a special irritability 
of the skin and the mucous membranes. 

The so-called “ periods of incubation” in syphilis do not, however, 
really exist. The words used to define them refer to periods of time 
in which, upon gross inspection, the evolution of the disease does not 
seem in progress, but when there is ample evidence that there is a 
gradual involvement of one portion of the body after another. Thus, 
in the “ second incubative period” of the text-books careful exami¬ 
nation of the patient about to display the external manifestations of 
systemic disease discloses the fact, as suggested above, that the symp¬ 
toms are by no means latent. The glands of many parts of the body 
outside those in the vicinity of the initial sclerosis become tumid and at 
times painful, including the tonsils and thyroid gland. The skin may 
exhibit icteroid symptoms as a result of hepatic disturbance; the excre¬ 
tion of urea may be augmented or albumin may temporarily appear in 
the urine; pains in the head, limbs, and other parts of the body may 
produce distress even of a severe grade; the leucocytes may relatively 
increase in number; the joints may become painful and swollen; and 
muscular contractures with many other evidences of a morbid state of 
the system may indicate to the careful observer that a general process 
of intoxication is in more or less rapid development. 

At this moment the “ second incubative period ” of the disease being 
completed, the patient is ready for an “ explosion ” of general syphilis. 
Insidiously or suddenly, first noticed upon the skin beneath the cloth¬ 
ing, with rapid efflorescence over the entire body-surface after a hot 
bath, the stimulus of liquor, or the excitement of the dance, appear 
the syphilodermata, or syphilides, the skin-symptoms of syphilis. 


Syphilodermata. 

(Syphilides.) 

The skin-manifestations of syphilis are of common occurrence, are 
numerous as to their forms, and are of the greatest importance from a 
diagnostic point of view. 

As in syphilis of other organs, that of the skin is betrayed in symp¬ 
toms like and unlike those of non-syphilitic affections. The study of 
these differences is here also a study of the syphilitic mode of disease. 
In a treatise of this scope and within these limits it will be proper to 
describe chiefly those evidences of the syphilitic process to be recognized 
in the integument. 

Lesions of the skin appear in syphilitic individuals of both sexes, in 
all periods of life, and in all stages of the disease. They are, how¬ 
ever, much more frequent during the first two years after infection, 
subsequent to which period the symptoms of the disease are more com¬ 
monly betrayed in subcutaneous lesions, or lesions which affect the 
viscera, and the osseous, nervous, muscular, and vascular systems. 

General Characteristics of the Syphilodermata. The syph¬ 
ilodermata, like chancres, are, properly speaking, modalities of such 


NEW-GROWTHS. 


605 


symptoms as occur in diseases not syphilitic. The distinctive differ¬ 
ence between the papules, ulcers, and other lesions of syphilis and those 
of lupus, for example, lies chiefly in the mode of evolution and involu¬ 
tion. It is the syphilitic behavior, rather than the syphilitic lesion, 
which guides the diagnostician. The syphilides, in short, resemble 
the lesions of most of the other diseases of the skin, and they differ 
also in various degrees from each one of the latter. Hence is seen the 
importance of a clear recognition of their general characteristics. 

Absence of Subjective Sensations. The eruptions produced by syphilis 
are rarely attended by itching, burning, or painful sensations of any 
sort. This absence is frequently a positive aid in establishing a diag¬ 
nosis, and, as a rule, is the more valuable the graver is the lesion. 
Great difference, however, will be noted in this respect between differ¬ 
ent individuals. Occasionally considerable itching will be perceived, 
as in condylomata of the anus; and syphilitic ulcers, especially of the 
leg, will be productive of severe pain. At the same time, it is a com¬ 
mon experience to find a patient quite tranquil as regards all subjective 
symptoms, covered from head to foot with a brilliant macular syphilo- 
derm, or exhibiting, with the utmost composure, an enormous number 
of serpiginous ulcerations on his scalp and extremities. 

Polymorphism (multiplicity of lesions of differing types), a term 
used to designate the coincident appearance of lesions of various char¬ 
acters upon one individual, is as true of syphilis as of other diseases, 
such as lepra and scabies. Viewing the cutaneous and other symp¬ 
toms of syphilis as a whole, this feature is strikingly significant, as it 
is possible to observe at one and the same time, upon the body of a 
single infected individual, symptoms indicative of pathological changes 
in the skin, mucous membranes, hair, nails, lymphatic glands, and 
periosteum. 

To a less marked degree is this true of the syphilodermata. The 
type of syphilitic skin-lesions is generally papular, and such lesions 
may originate from macules, enlarge into tubercles, or degenerate into 
ulcers. The simultaneous coexistence of several of these forms is often 
due, as Bumstead and Taylor have well shown, to their chronicity, 
their tendency to recurrence, and to the changes which they undergo. 

Career. The historical course of the syphilides suggests certain com¬ 
mon features. They are rarely accompanied by local inflammation, and, 
with the exception of syphilitic fever, are usually unattended with 
pyrexia or with malaise. The tolerance by the general economy of 
an extensively developed syphiloderm is highly significant of the 
disease. Again, though generally described as a chronic disease, syph¬ 
ilis is, judged with respect merely to time, much more acute than sev¬ 
eral other maladies. The syphilides have a distinct career, pursuing, 
even when untreated, a natural process of evolution and involution, 
and few, save those upon the lower extremities, where the force of 
gravity is an important element in the fixation of all local disease, 
persist in unvarying type for any lengthened period of time. One lesion 
is apt to succeed another by development or by degeneration; and 
many of the untreated syphilides disappear without leaving relics of 
their existence upon the surface of the skin. In these last-named 


606 


DISEASES OF THE SKIN. 


particulars syphilitic cutaneous manifestations are singularly different 
from those of lupus and of carcinoma, for example, where the lesion 
is usually of one type, and persists in one location for a period of 
time during which a syphilide would have progressed either to much 
more extensive damage or to permanent repair. 

Color. There is no color peculiar to the syphilodermata that may 
not be seen in other diseases of the skin. It is important to recognize 
this fact clearly, as there are those who claim to diagnosticate the syph- 
ilides by their hue alone. The color, however, considered in connec¬ 
tion with the other features of the syphilides, is highly characteristic, 
and often is sufficient to enable one at a glance to identify the nature 
of the disease. These color-shades are usually less brilliant than those 
seen in other cutaneous diseases, and they possess less of the scarlet 
and crimson quality. They are admixtures of red, yellow, and brown, 
in various proportions, frequently with a slight preponderance of the 
brown. They have been compared with the color of raw ham and 
with that of copper, hues which have unfortunately been so associated 
with the syphilides that the non-recognition of such peculiarity has led 
to many errors in diagnosis. Pigmentation in various shades of choco¬ 
late, coffee, and black are recognized among the syphilides, both during 
their evolution and after completion of their involution. In cases 
where there has been no luetic affection the color, as in syphilis, is 
due to increase of pigment in the part, both with and without extrav¬ 
asation of blood. Recent syphilitic scars are usually pigmented both 
in centre and periphery. Here, also, it is not so much the color as it 
is the scar with the color which gives special significance to such lesion- 
relics. 

Contour. In syphilis the contour of single elementary cutaneous 
lesions, as also of a group of aggregated lesions, is usually circular, 
or there is a distinct tendency to assume such a configuration. Thus, it 
is common to find outlines of patches, ulcers, and scars observing the 
curve of a segment of a circle, and the coalescence of several such 
lesions tends to produce the serpiginous aspect. Figures resembling 
the horseshoe, the kidney, the half-moon, the letter S, and the dumb¬ 
bell are thus produced. The earlier exanthems of syphilis are usually 
symmetrical, the later are asymmetrical. Even symmetrically dis¬ 
tributed eruptions will at times occur in annular patches, made up 
of maculo-papular lesions arranged in a circular or a crescentic line. 
Patches of syphilitic eruption will often clear up at the centre and 
develop or spread at the circumference of a circle. 

Site. No portion of the skin is free from the possibility of in¬ 
vasion by syphilis. The disease may involve at once almost the 
entire integument, or it may rapidly spread from point to point, hav¬ 
ing covered finally a large area, or it may appear conspicuously at 
distant and isolated points of limited extent, or, finally, it may exclu¬ 
sively be manifested in an insignificant lesion or a group of lesions, 
ephemeral in course, and limited to one portion of the body. The 
site of a syphilitic eruption may be determined apparently by the 
capriciousness of' the disease, and yet result from local irritation of the 
skin of infected individuals. The accumulations on the napkins of 


NEW-GROWTHS. 


607 


women invite the occurrence of labial condylomata; the lips of the 
infant, after contact with the nipple of the mother, become the seat of 
rhagades and fissures; while the tongue of the tobacco-chewer and the 
fauces of the tobacco-smoker acknowledge special sources of mischief. 

There are some sites of preference for special lesions, as, for example, 
the squamous sypbiloderm of the palms and soles, and the papules of 
the forehead, constituting the so-called “ corona veneris.” 

Amenability to Treatment. Mercury possesses a singular influence 
upon the syphilodermata that is promptly perceived when the drug 
is internally administered. This singularity rests upon the broad fact 
that the lesions of many other cutaneous diseases not only refuse to 
acknowledge the benefit of such medication, but in many cases are also 
aggravated by it. The importance of clearly recognizing the character 
of each cutaneous disorder submitted to treatment is thus well illus¬ 
trated. 


Fig. 72. 



Facial cicatrices of tubercular syphilodermata after twenty-five years of infection. 

(From a photograph.) 

Characters of Special Lesions. Certain families of symptoms in 
syphilis exhibit characteristic features. Thus, some papular lesions are 
surrounded at the base by a peculiar fraying of the epidermis, in con¬ 
sequence of which they are encircled by a little fringe of scales resem¬ 
bling in shape a collar. The scales ol syphilis are usually not abundant, 
but are fine, dirty-whitish or occasionally brownish in color. The 
crusts of syphilis are apt to be bulky, greenish-black in hue, and to 
surmount secreting ulcers of various depths. Such ulcers are gener¬ 
ally circular, or they exhibit in contour a tendency to assume the cir- 


608 


DISEASES OF THE SKIN. 


cular line, while the cicatrices by which they are succeeded have a 
similar configuration. The scars of syphilis are frequently smooth, 
delicate, very slightly depressed, unattached to subjacent tissues, and 
pigmented. Lastly, from several of the secreting lesions of syphilis, 
especially those upon and about the ano-genital region, proceeds a dis¬ 
charge having an offensive odor, and capable of communicating the 
disease to a sound individual by inoculation. 

Subjection to External Agents Capable of Exerting an Influence upon 
Non-syphilitic Eruptions. It is an obvious error to conclude that the 
exanthemata of syphilis are produced exclusively by the operation of 
a systemic intoxicaton. Many of the pustular syphilodermata are the 
result solely of pyogenic cocci, and their extension may be by inocula¬ 
tion and auto inoculation. This fact is shown not merely by the ordi¬ 
nary methods of demonstration, but also by the clinical fact that 
these lesions are far more numerous among the filthy, the neglected, 
and the ignorant. Often syphilodermata are commingled with sebor¬ 
rheic and eczematous affections. It is not rare to find patients applying 
for relief in clinical practice who exhibit lesions of syphilis commingled 
with traces of the incursions of lice and bugs, urticarial wheals, scratch- 
marks, and forms of keratosis pilaris, due to the unwashed condition 
of the skin. 


Syphiloderma Maculosum. 

The cutaneous lesions of syphilis, limited to color-changes in more 
or less circumscribed areas of the skin, are exhibited in two distinct 
forms, due respectively to anomalies in blood- and pigment-distribution. 

(1) Syphiloderma Maculosum due to Hyperemia. [Ery¬ 
thematous Syphilide, Syphilitic Roseola.] This form of mac¬ 
ular syphiloderm is the earliest expression of cutaneous syphilis, and 
is more or less constant of occurrence, differing in this respect from 
several of the other syphilides. It is often unnoticed by the patient, 
whose attention may first be called to it after its recognition by the 
skilled eye of another. It occurs in coffee-bean- to filbert-sized 
macules, roundish, oval-shaped, or of irregular contour, and varying in 
color from a light rosy to a dull mulberry hue. In some cases these 
markings of the skin-surface are very indistinct, requiring for their 
recognition the closest scrutiny in a clear light, and occasionally even 
then leaving uncertainty in the mind of the expert. At times they 
constitute an irregular “ marbling” of the surface, of a kind which 
renders it difficult to define with the eye the individual lesions com¬ 
posing the eruption, while the general visual effect of the exanthem 
is exceedingly distinct. The spots are not elevated above the general 
level of the integument, but may change in type, a papular lesion 
developing later in the same site. 

Like all macules of the skin due to vascular changes, they vary in 
color with the complexion of the individual, with the time which elapses 
after their first appearance, and with vascular changes in the superficial 
plexus of blood-vessels. Thus, the deeper shades are usually observed 


NEW-GROWTHS. 


609 


in thick and muddy-tinted skins; the more delicate shades upon the 
breast, for example, of blonde women. 

The eruption usually appears between the sixth and the eighth week 
after the appearance of the initial sclerosis, and, when untreated, de¬ 
velops for about one week more. It persists for a variable period of 
time, depending upon the severity of the constitutional disorder and 
the treatment to which the patient is subjected. During the early part 
of its career the hue of the lesions is lighter, and they may be made 
to disappear under pressure of the finger; later, they are more deeply 
stained, and, exudation having occurred, the color of the spot does not 
disappear under pressure. When involution is in progress there is a 
slow disappearance of all symptoms of the eruption, which gradually 
fades from view. The vascular changes in the capillaries, occasioned 
by cold, heat, and rapid cardiac contractions, influence the eruption 
to a marked degree. A hot bath, a dance, a glass of spirits, a fit of 
excessive coughing, laughter, etc., may all bring the lesions into 
prominence. 

The eruption may be limited to the skin of the belly, extending 
sparsely over the chest, the loins, the anogenital region, and the thighs; 
over the palms, soles, forearms, and legs; or, in exceptional cases, may 
profusely cover the entire surface of the body (face, ears, dorsal sur¬ 
faces of the hands and feet, and skin of the penis with the progenital 
region). In the milder forms it is evidently susceptible to external 
irritation of the skin, as it is common at the wrists where a starched 
cuff is worn, over the brow in the line covered by the hatband, and is 
particularly well developed in men where the trousers are “ rein¬ 
forced” (perineum and inner faces of the thighs). 

At times, as in the exanthematous fevers, the eruption is preceded 
by a febrile state, with marked amelioration of symptoms when the 
rash is fully developed; while, again, it is throughout accompanied 
by slight rise in the body-temperature, the patient having the so- 
called 11 bilious” appearance—muddy complexion, coated tongue, 
icteroid hue of conjunctive, and offensive condition of the breath. 
Wandering pains in the extremities, and especially beneath the ster¬ 
num, are frequently experienced. The last-mentioned symptom is 
highly significant, and the whole condition is probably due to the 
effect upon the nervous system of the circulation of the recently intox¬ 
icated blood. These pains are not those produced later in the periosteal 
and other complications of the disease, and are the more significant 
as the eruption itself is productive of a scarcely appreciable subjective 
sensation. The superficial ganglia of the body are usually engorged 
at the same time; the fauces are congested; the hairs of the scalp are 
slightly loosened in their follicles, and, in the latter region, in severe 
.cases, papules and pustules may form. Inasmuch as the order of 
sequence of phenomena in syphilis is subject to a singular inversion, 
it occasionally happens that there is concomitance of later signs of the 
disease, such as iritis, affection of the nails and bones, or even, in 
places, of pustular, papular, or squamous syphilodermata. 

Much less rare is the survival of the initial sclerosis to the date of 
this efflorescence. This point is of considerable importance. The 

39 


610 


DISEASES OF THE SKIN. 


physician should never conclude the examination of a patient com¬ 
plaining of suspicious genital lesions without carefully exploring the 
surface of the trunk, and also never pronounce upon an exanthem of 
this sort without minute inspection and palpation of the part where an 
initial sclerosis may exist. In a diagnostic and therapeutic sense the 
information thus gained may be precious, and, in a large proportion 
of all cases, is of a kind quite hidden from the knowledge of the 
patient. 

Relapses occur in certain cases with limitation of the disease to parts 
previously affected or unaffected. At the end of the first twelve 
months recrudescence of larger macules in annular groups may occur. 
Exceptional forms are noted where darker puncta appear in the macu¬ 
lar lesion, occasionally traversed by a hair. These puncta are local¬ 
izations of a more intensely hyperemic or exudative condition about 
the orifices of the ducts of the follicles. 

The diagnosis of this syphiloderm is readily established in view 
of its essentially symptomatic character. From scarlatina, measles, 
and rotheln it differs in the indolence of the rash, the absence of 
decided elevation of body-temperature, and the order of its appear¬ 
ance in different portions of the body, as it rarely occurs first upon 
the face. Urticaria and the rashes induced by the ingestion of copaiba 
and other medicaments are distinguished by the marked itching of the 
affected surface and by their very general diffusion over the entire 
body, a condition rarely observed in the syphiloderm. Tinea versi¬ 
color, usually limited to the anterior surface of the trunk, is character¬ 
ized by a fawn-colored to a chocolate colored tint, by the furfuraceous 
desquamation which the patient usually describes as most noticeable 
after a hot bath, and by the existence of the readily recognized vege¬ 
table parasite upon the scales scraped from the affected surface. Tinea 
versicolor is, moreover, of much longer duration than a syphiloderm, 
and never extends to the exposed parts of the body—the face and the 
hands. Ringworm of the skin of the body is not symmetrical, and 
is a parasitic disease. 

All these distinctions, however, are not to be compared for a moment 
in their diagnostic value with the concomitant symptoms of syphilis 
that are very geuerally present, such as adenopathy, persistence of the 
initial sclerosis, and evident involvement of other than cutaneous 
tissues. Such concomitant symptoms will be found occasionally with 
a non-syphilitic eruption due to drugs ingested for relief of the infec¬ 
tious disease. The most common of these drugs is the iodid of potas¬ 
sium; the eruptions it produces are frequently found botli commingled 
with the macular syphiloderm and occurring on the eve of the appear¬ 
ance of the latter. The existence of acneiform lesions upon the face, 
the neck, and the posterior surface of the trunk, a vivid erythema of 
the forearms, including the hands, and purpura-like maculations of 
the face, legs, and feet, should never mislead the physician as to the 
character of the disorder with which he is confronted. It is unde¬ 
veloped syphilis with a dermatitis medicamentosa of the surface. 
Suspension of the iodid, which fortunately is not required in the 
immense majority of cases; the use of a properly selected mercurial, 


NEW-GROWTHS. 


611 


or even (and this is often wise) abstention from all medication, will be 
succeeded by disappearance of the cutaneous lesions, which may be fol¬ 
lowed later by a mild macular syphiloderm, altogether insignificant in 
comparison with the eruption artificially induced. 

2. Syphiloderma Maculosum due to Anomalous Distribu¬ 
tion of Pigment (Pigmentary Syphilide). This eruption, if it 
may be so called, is occasioned by the appearance upon the body-surface 
of irregularly circular, usually poorly defined, dirty-brown and choco¬ 
late-tinted macules, which, as they are entirely unconnected with vascu¬ 
lar changes, do not disappear under pressure. The lesions occur as 
sparse well-isolated discolorations, or, more commonly after a species of 
confluence, as an irregular rete or network, with relatively large inter¬ 
spaces characterized by an absence of coloration. The eruption is 
most common upon the sides of the neck, especially in blonde women, 
though it may more rarely involve the surface of the trunk and the 
extremities. It is also most frequent during the first year after in¬ 
fection, though it may develop later. 

It occurs: (a) as a sequel to a macular or maculo-papular syphilo¬ 
derm over the parts described above; and (6) ab origine, as a pigment- 
disorder, probably under the same influences as those productive of 
the chloasmata of symptomatic origin (chloasma uterinum, cachecti- 
corum, etc.) 

According to Fox, of New York, the color-changes observed in the 
skin are explained by the occurrence: first, of pigmentary deposits, 
chiefly at the centre of the ordinary macular or papular syphiloderm; 
secondly, of peripheral absorption of such pigment-deposit with possi¬ 
ble persistence of it for a variable time at the centre of the lesion; 
thirdly, of total absorption of all pigment from the original lesion ; 
and, lastly, of peripheral hyperpigmentation of the spaces interme¬ 
diate between the original macules. 

The eruption is an epiphenomenon of the syphilitic process, being 
not amenable to the treatment under which other macular syphiloder- 
mata speedily disappear, and is an expression rather of general deteri¬ 
oration of the health of the skin than of specific disease. 1 

The eruption is liable to be mistaken for that condition in which 
there is simply an accumulation, upon a somewhat greasy skin, of 
secretions and dust, to be seen upon the integument long unwashed. 
Tinea versicolor has a more yellowish or fawn-colored tint, and is more 
abundantly developed upon the front of the chest than upon the neck. 
Neither vitiligo nor leucoderma is symmetrically disposed, as is usually 
the case with the pigmentary macular syphiloderm. 


Syphiloderma Papulosum. 

The type of all cutaneous lesions produced by syphilis is to be recog¬ 
nized in the papule. Most of the other lesions are either developed 

1 This eruption is often very perfectly developed upon the skin of Chinese patients affected with 
syphilis. 


612 


DISEASES OF THE SKIN. 


from it, transformed to it, or by reversion or admixture confess that 
the neoplasm of syphilis in the skin is essentially a more or less solid 
circumscribed cutaneous lesion, varying as to size and history. 

Papules, occurring in syphilis, may appear as the first cutaneous 
evidence of infection, or they may be developed from earlier macules. 
They may be small, large, acuminate, flat, disseminated, or in groups. 

Small Acuminate Papular Syphiloderm. In this eruption 
the lesions are millet-seed- to hemp-seed-sized, circumscribed, globular, 
acuminate, reddish and salmon-reddish, firm elevations of the surface, 
or minute nodules upon the skin, generally symmetrically developed, 
often over the entire body, closely set together and occasionally grouped 



Syphiloderma papulosum (after Jullien). 


in crescentic figures. When viewed with care a minute vesicle, a 
pustule, or a scale may often be detected at the conical apex of each 
papule, the vesicular or pustular lesions rarely developing to such an 
extent as to become a characteristic feature of the eruption. The 
color is at first, especially in blonde skins, a species of salmon and-red, 
mixed; later, the darker and browner shades appear. When general¬ 
ized the eruption is well developed, especially over the posterior face 
of the body, the occipito-cervical and scapular regions, the buttocks, 
and the calves of the legs, though it is often distinct about the anus 
and the genitalia. Like several other of the syphilodermata, its earlier 
are more symmetrical than its later manifestations, whether these be 
tardy or relapsing, or both. The involution occurs by resorption of 
the plastic exudate, minute and usually scanty, dirty-whitish colored 





NEW-GROWTHS. 


613 


scales encircling the base of each lesion. When the eruption has 
proved especially persistent, marked pigmentation follows in the form 
of brownish-red blotches, the centre of each of which displays a cica- 
triform relic in the form of a punctum. 

The eruption is often first noticed about the forehead, nose, mouth, 
and neck, localities commonly subject to topical irritation. Thus, about 
the forehead in men, the papules will frequently be arranged along 
the band pressed by the lining of the hat; and the frequent fingering 
of the face, shaving, and irritation by the edge of the collar of the 
shirt, may determine a more speedy efflorescence at the sites of contact. 
About the mouth tobacco plays the part of an excitant; about the 
nose a localized seborrhea may be added to the syphilitic phenomena, 
in which case the lesions may be covered with thin, greasy crusts. 
The eruption is common during the first six months after infection, and 
is usually fully developed after a fortnight when no treatment has influ¬ 
enced its evolution. When the lesions are perforated by hairs they 
suggest, on superficial examination, a resemblance to keratosis pilaris; 
and when aggregated in patches of distinct contour they might be 
confounded with psoriasis or squamous eczema. But in every case the 
general physiognomy of the disease may well be trusted for the estab¬ 
lishment of a diagnosis, having in mind the color, the absence of 
intense pruritus and serous exudation, the disposition over the body 
as a whole, or in portions widely separated, and the rarely failing 
concomitant evidence of syphilitic infection. 

Large Acuminate Papular Syphiloderm. Lesions of the 
character above described occasionally develop to an unusual degree, 
attaining the size of that of a coffee-bean in localities where the apex 
of each lesion is free to push forward without coming into contact with 
adjacent planes of the integument. Thus, about the dorsum of the 
body, the gluteal regions, the calves of the legs, and the extensor 
surfaces of the forearms, they occur as fully developed, slightly scale- 
capped or scale-encircled, and grouped papules often commingled with 
pustules and superficial ulcers, the polymorphic patch having a figure- 
of-eight or S-shaped outline. These patches are apt to occur in patients 
under treatment, the influence of which has interfered with the full 
evolution of the disease. 

Small Flat Papular Syphiloderm. The lesions recognized 
under this title differ from those just described in that they are not 
acuminate, but are distinctly flattened at the apex, this flattening being 
at times so pronounced that each lesion resembles a small button or a 
plaque, the contour being roundish or oval-shaped. The lesions are 
frequently encountered on the face, especially near the mucous outlets, 
over the anterior and posterior surfaces of the trunk, and on the flexor 
aspects of the extremities. The palms of the hands are often affected. 
In color they exhibit the variation usual in individuals of different 
complexions and in the same individual, according to the condition of 
the circulation. Thus, on the face, a scarcely distinguishable pink 
will become a deep, lurid, reddish-brown from an attack of sneezing, a 


614 


DISEASES OF THE SKIN . 


paroxysm of laughter or of rage, and from violent exercise. The 
seborrheic condition noted on the face in the acuminate lesions is also 
occasionally seen about the plaques. The same is true of the scaling 
described above. The eruption is much less copious, as a rule, than 
with other forms of syphilitic papules, due doubtless to the fact of its 
frequent occurrence in those subject to some treatment. The papule 
differs from the lesion about to be described with respect to its size, 
being rarely larger than the size of small buttons; while the largest 
papules of the same variety may attain the size of that of large coins. 
The diagnosis is in general that already given. 

Large Flat Papular Syphiloderm. Here the resemblance of 
the papule to a button is even more distinct, the lesion occurring with 
a well-defined, firm, raised border, and a shallow depression in the 
centre, though at times, especially in moist situations, the superficies 
of the plaques is a smooth, flat plane. The large papules commonly 
begin as macular lesions and rapidly develop at the periphery, this 
development often corresponding with centric involution, by which the 
shallow depression described above is reduced to the level of the adjacent 
skin and the lesion is transformed into a ring. In shape the papules 
are circular and oval; in size they vary from that of a finger-nail to 
that of the section of a pigeon’s egg. They have the usual variation in 
color, and may scale at the edge, or over the flat top or the depressed 
centre. In moist situations they frequently secrete a muco-purulent 
fluid which smears the papules and adjacent integument, and which, in 
the vicinity of the anus or genitals, exhales an offensive odor. It is 
especially in such situations that they occasionally degenerate by fissure 
or by circular ulceration. Condylomata Lata are such lesions, 
being flat and secreting papules of the region named, and having a 
whitish appearance in consequence of the mucoid secretion with which 
they are smeared, and somewhat transformed by the influence of heat, 
moisture, and either friction or apposition of contiguous integumentaiy 
folds. 

Papular syphilodermata may become generalized or be limited to 
certain sites of preference, as the face, the neck, the flexor surfaces of 
the extremities, and the anogenital region. It is either an early, a 
late, or an intermediate symptom of syphilis, occurring most abundantly 
in young and delicate skins, where the disease has been ignored and 
therefore untreated; and most scantily in the thicker integument of 
middle life, where prompt resort has been had to appropriate medi¬ 
cation. 

Syphilitic papules undergo a series of modifications, under the influ¬ 
ence of various causes, which may be enumerated as follows: 

(a) There is considerable hyperplasia of the cutaneous elements (papil¬ 
lary layer of the corium, rete, and blood-vessels), by which the papule 
becomes largely raised from the surface, so as to resemble a papilloma 
or wart, or the lesions characteristic of frambesia. In this way, rarely, 
a portion or the entire surface of the body may be covered with light- 
red or violaceous-red, non ulcerative, vegetating growths. They secrete 
freely, and the discharge is liable to concrete into crusts, and to exhale 


NEW-GROWTHS. 


615 


an offensive odor. De Amicis 1 described a marked instance of this 
lesion occurring upon the scalp, under the title of ‘ * frambesioid con- 
dylomatous syphiloderm.” A translation of his paper by the author 
appeared in the Archives of Dermatology for October, 1879 (p. 39). 

( b ) There is considerable hyperplasia of the elements, in consequence 
of which the lesion spreads laterally, while its elevation from the sur¬ 
face is prevented by contact with apposed surfaces. Thus is formed 
the broad, flat, moist papule known as the u vegetating mucous patch,” 
<c condyloma,” 'plaque muqueuse, etc. (Fig. 74). The lesions, when 
unaltered and fully developed, are of a decidedly whitish color, from 
the puriform mucus which covers them and which, as with so many 
of the syphilodermata in moist situations, is liable to exhale an ex¬ 
tremely offensive odor. When the secretion is removed the lesion is 
seen to be pinkish, or light- or dark-red in color, and to be either firm 
or soft, scarcely raised, and indefinite in contour, or distinctly elevated 
and very well defined. They are chiefly found in moist situations, 
where folds of the skin are apposed, as about the perineum, the groins, 
the axillae, the mammae, the nates, the anus, the genitals, and the 


Fig. 74. 



Vegetating condylomata of the vulva (after Jullien). 


inner faces of the thighs. They may coalesce so as to form palm¬ 
sized patches, and frequently they are associated with hyperidrosis, 
seborrhea oleosa, and the dried products of secretion from the adjacent 
mucous outlets. 

(c) In consequence of changes in the superficial layers of the epider¬ 
mis the papules may become covered with scales, either at the base or 
the apex, more commonly the latter, forming thus the papulo-squamous 
syphiloderm. The scales are of a dirty-grayish hue, often desiccated, 
generally attached, rarely freely exfoliating. They are relatively few, 
occurring where the lesions are closely set together. The desquamation 
may be the most suggestive feature of the patch. Beneath the scales 
are seen distinctly elevated brownish-red papules or merely slightly 
elevated, dull-red or purplish-red maculations. When the scales accum¬ 
ulate at the base of the papule they tend to surround it with a circlet 
or collarette of exfoliated shreds of epidermis. 


i Annal. Clin, de Osped. Incurab. 


616 


DISEASES OF THE SKIN. 


In consequence of the thickness of the epidermis in the palms and 
soles, the papular or papulo-squamous syphiloderm of these regions is 
presented under somewhat atypical forms, which are recognized as the 
Palmar and the Plantar Syphilides. The dense stratum corneum 
of the epidermis in the palms and soles is not readily raised from its 
underlying tissue into papular forms. The pathological manifestations 
of this disease are rather displayed in thickenings, separations, stain- 
ings, and frayings. 



Fig. 75. 


Palmar syphiloderm (after Keyes). 


Here, therefore, are seen dull-red maculations, covered throughout? 
or merely at the edges, by scales or epidermal shreds; minute, firm, 
corneous thickenings, few or many, often without color in consequence 
of the depth of the blood-vessels beneath the opaque horny layer; and 
distinctly elevated (not flattened) and circumscribed papules, of the 
usual livid-red color, coffee-bean- to small-nut-sized, often aggregated 
in patches having a tendency to assume the circinate outline. Occasion¬ 
ally pin-head-sized and larger deposits resembling chalk may be picked 
with a pointed instrument from circular beds in the palms and soles 
where the lesions first developed. These and similar spots may be 
covered with dirty-whitish, tenacious, half-loosened, epidermic flakes, 
which are quite characteristic. In other cases, usually in consequence 
of the motions of the hand or the foot or the exigencies of toil, there 
are visible irregular angular losses of epidermis resembling the fracture 
of a pane of glass. The attached portions of the epidermis project at 
the edges only, over deep fissures, broad exulcerations, or a ham-red, 
tender, and newly formed epidermic stratum. 

The eruption is frequently symmetrical in the centre of both the 
palms and the soles, rarely upon the dorsum of the hands and the 
feet, and then never typical but always by extension from the former 
regions; also on the lateral surfaces of the hands, feet, fingers, and 
toes, as well as the wrists and ankles. The eruption is a persistent, 
rebellious, and usually late cutaneous symptom of syphilis, occurring 
often six, eight, and more years after infection. Rarely it is seen 



NEW-GROWTIIS. 


617 


within a few months after the existence of chancre, and is then usually 
manifested in its simpler forms. 

The papulo-squamous syphiloderm bears in many instances a strong 
resemblance to the patches of psoriasis, but it can usually readily be 
distinguished from the latter by a consideration of the following 
points: 

The syphilide, as a rule, is not generally diffused; it displays sym¬ 
metry only when it involves the palms and soles; it is elevated at the 
border of the patch; and it observes the contour of the segment of a 
circle. Psoriasis is more widely diffused; is generally symmetrical; 
is not specially elevated at the border of the patches, and the latter are 
rather more completely than partially circular in outline. In syphilis 
there is generally a history of infection, of other cutaneous or mucous 
symptoms of the disease, and, in married women, of abortions, mis¬ 
carriages, or births of diseased children, all of which are wanting in 
psoriasis. In psoriasis there is a decided predisposition to the devel¬ 
opment of the disease about the extensor surfaces of the joints and the 
posterior aspect of the trunk; the syphiloderm, though it may occupy 
these situations, can rarely be found thus displayed when the other 
surfaces are spared. The scales in psoriasis are more lustrous, are 
more freely produced and shed, and they exist significantly at an earlier 
period of the exanthem. It may safely be said that, with only such 
exceptions as prove the rule, psoriasis is never strictly limited to the 
regions of the palms and soles. A scaling palmar or plantar disease 
of the skin in childhood is more apt to be psoriatic, though both dis¬ 
eases are seen in the early periods of puberty. 

Eczema is yet more readily recognized by its severe itching, its his¬ 
tory of discharge and moisture, and its characteristic crusts. Ancient 
patches of squamous eczema are often very indeterminate in outline, 
they do not ulcerate, and they exhibit scales on the surface of a 
much more deeply infiltrated area. Eczema of the palms and soles, 
when chronic, usually iuvolves also the dorsum of the hands and the 
feet. When this is not the case, the eczematous infiltration, if of long 
duration, will, in the vast majority of all cases, be found to involve 
uniformly and evenly the entire palm or sole, including the palmar or 
the plantar faces of the digits. Eczema, finally, is much more fre¬ 
quently encountered solely upon the right hand in right-handed patients, 
or to a greater extent in that organ by reason of its preference in the 
performance of function. This is less common in syphilis. 


Syphiloderma Vesiculosum. 

Vesicular syphilodermata are either the rarest of all cutaneous 
symptoms of syphilis or they do not actually exist. Certain Freuch 
authors describe pin-head- to pea-sized, conical, globoid or umbilicated, 
isolated or grouped, and crusting elevations of the epidermis, with 
lucid or cloudy contents, seated upon the face and the genitalia. The 
eruption is described as an early syphiloderm, often exhibiting a halo 
of characteristic tint, the resulting crusts being granular and somewhat 


618 


DISEASES OF THE SKIN. 


lighter in color than those commonly seen in the disease. Both small 
and large vesicles have thus been assigned to the disease. 

But the larger number of the lesions are, without question, either 
immature pustules, eczematous lesions in syphilitic subjects, or pure 
accidents of the syphilitic process. With regard to the first, it may 
be said that the pustular syphiloderm not rarely begins as a vesicular 
lesion; with regard to the second, that coincidences of so common a 
disease as syphilis with other cutaneous disorders is a matter of fre¬ 
quent observation; and with regard to the third, bearing in mind the 
large quantity of iodid of potassium swallowed for the relief of the 
disease and its capability of exciting a vesicular eruption, it can reason¬ 
ably be concluded that some, at least, of the cases of so-called u vesic¬ 
ular syphilis” have imperfectly been studied. 


Syphiloderma Pustulosum. 

In the ight of modern knowledge on the subject of the relation of 
micro-organisms to disease it is safe to assert of the larger number of 
all pustular affections of the skin, whether in syphilitic or in non¬ 
syphilitic subjects, that they are the results of infection with pus-cocci. 
It is therefore not sufficient in syphilis to pronounce as to the question 
of infection only. It is necessary further to explain many of the 
external phenomena of the disease by the accidents to which non¬ 
syphilitic patients are subject. 

These accidents are probably of more frequent occurrence in pustular 
syphilodermata than in any other lesions exhibited in the disease. 
Viewed as a whole, it is noticeable that pustules occur for the most 
part in dispensary and hospital practice, among the impoverished, the 
filthy, the ill-housed, and the poorly treated. They are decidedly rare 
in the clientele of Ihe physician consulted chiefly by those who are 
cleanly, well-nourished, and skilfully treated. If it were possible to 
keep the skin of the syphilitic subject aseptic during the management of 
the disease, no one would expect an evolution of pustular syphiloder¬ 
mata at any time throughout its course. The lesions described under 
this title may therefore be regarded for the most part as due to the causes 
suggested above, aided by picking and scratching the skin to an extent 
capable of distributing staphylococci over its surface. In other cases 
we are not yet in a position to deny that pustules, general of evolution 
and characteristic in appearance, may develop in consequence of luetic 
infection only, but even of this type they are rarely to be seen in the 
better class of patients. 

Pustular lesions in syphilis, furthermore, present a wide range of 
differences. They may vary in size from that of a pin-head to that of 
a finger-nail; they may be acuminate, flat, hemispherical, or irregular 
in shape; they may be few or be very numerous; they may be dis¬ 
tinctly localized or be generally dispersed; they may be grouped or be 
disseminated; and they may occur from the first as minute vesico- 
pustules, or as pustular transformations of variously-sized papules. 
They may be surrounded by inflammatory areolae, or may spring from 







Large Pustulo-crustaceous Syphiloderm of the Scalp and Body. 


[From a photograph ot a cachectic clinical patient.] 




NEW-GROWTHS. 


619 


an unaltered integument, or be subepidermic in situation, and scarcely 
project from the surface. They may be seated upon superficial or deep, 
or sharply cut, secretory ulcers, and they are usually covered by 
crusts differing in bulk and consistency, forming thus the pustulo- 
crustaceous syphilide. According to the depth of the ulceration at 
the base are they followed by cicatrices. Pigmentation is a frequent 
result. The crusts which form by the desiccation of pus are usually 
reddish-brown to greenish-black in hue, they occur in strata or laminae 
by accretions from beneath, and, even when superimposed upon a moist 
and secreting ulcer, they are quite adherent at the edges. They may 
occur early or late in the disease, and at either epoch may constitute 
trifling or grave cutaneous lesions. They have a marked predisposi¬ 
tion for involvement of the sebaceous and pilary follicles, and they 
are frequently disposed about the mucous outlets of the body. 

Small Acuminate Pustular Syphiloderm. This exanthem, 
which is usually largely diffused over an extensive surface, probably rep¬ 
resents, as Jullien has suggested, a transformation from papular lesions, 
due to pus-infection in skins that are usually unclean, irritated, or the 
seat of diminished vitality. The eruption is certainly rare in patients 
of the better class. The pustules are generally recognized about the 
pilo-sebaceous orifices, and upon minute papular lesions, which, as 
undisguised elements of the eruption, may be interspersed among the 
latter. The pustules are acuminate and contain each but a droplet 
of cloudy serum or pus, the desiccation of which furnishes a thin 
yellowish or reddish brown crust. The fall of the latter exposes the 
grayish epidermal fringe of the base occasionally seen in papules of 
similar size. 

The lesions may be discrete, confluent, disseminated, or in groups 
affecting the curve of a circle. The extremities and the trunk are 
chiefly involved, though the disease may well-nigh be universal. 
Under the influence of treatment there form minute, punctiform, and 
pigmented cicatricial atrophic depressions which are not persistent. 
The eruption may be an early or a late secondary symptom, but usually 
it is first seen within a few months after infection. Relapses occur when 
treatment has irregularly been pursued. Frequent concomitants are 
those symptoms of syphilis proper to the period in which they appear. 

Large Acuminate Pustular Syphiloderm. The lesions are 
here usually coffee-bean-sized pustules, which may spring from macular 
or smaller pustular lesions, very rarely from an indurated or a papular 
base. They have a thin roof-wall, occurring by preference where the 
epidermis is delicate, and they are surrounded by a halo. They are 
usually acuminate, but they may, after full evolution, slightly flatten 
at the apex in consequence of partial collapse. The crusts are bulkier 
and darker in color than those of the lesions just described; their bases 
are superficially ulcerated. The pustules form slowly or rapidly, in 
disseminated or in grouped forms, usually at an early period of the 
disease, though commonly after the appearance of some syphilide of 
another type. 


620 


DISEASES OF THE SKIN. 


Small Flat Pustular Syphiloderm. This is a relatively fre¬ 
quent manifestation of syphilis, occurring upon the face, the scalp, the 
trunk, and the flexor surface of the extremities. The exanthem ex¬ 
hibits a decided tendency to characteristic and circular grouping about 
the mucous outlets of the body. Such groups are composed of small, 
flat pustules, originating as reddish, macular lesions which tend to dry 
into flattish, irregular, adherent crusts. These crusts either surpass the 
limits of the diseased surface beneath, or are conspicuous upon a dull 
brownish-red area of inflamed, and at times even of ulcerated aspect. 

Often the pustules are so closely set as to become confluent, in which 
case a single convex crust, like a carapace, will often completely cover 
the involved area. Frequent sites of the exanthem are the regions 
about the nose and the lips, as also the chin, cheeks, and the anterior 
faces of the elbow and wrist-joints. 

The eruption is of pustulo-crustaceous type, and it may be evolved 
from either papular or macular lesions. In the United States 
it is rarely long untreated, and is therefore not often presented for 
observation when in full evolution. It is usually amenable to judicious 
treatment; when followed by severe ulceration, destroying one ala of 
the nose or a part of the lip, the patient has usually suffered from 
either cachexia or neglect. In these cases less severe phenomena are 
presented in the superficial serpiginous syphilide, the lesions extending 
in circinate or annular gyrations about a sound or a previously involved 
and healed centre. Thus, a circlet of crusts, with underspreading 
superficial ulceration, perhaps alternating with pustules of various 
ages and reniform cicatrices, will surround the elbow or traverse the 
scalp. The resemblance to pustular eczema is at times suggestive, but 
the ulceratiou and outline will aid in their discrimination. The lesions 
are usually late among the earlier symptoms of the disease, but they 
may be delayed for six months after infection. They indicate, as a 
rule, either severity of the disease, or, much more commonly, constitu¬ 
tional impairment. 

Large Flat Pustular Syphiloderm. The lesions here are, 
naturally, fully developed forms of those described above. They orig¬ 
inate as usually numerous, maculo-papular symptoms, which gradually 
deepen into pea-sized and even larger flat pustules, whose further his¬ 
tory is one of enlarging, blood-mixed, reddish- and greenish-brown, 
also flattish, crusts with underspeading pus-bathed ulceration of vary¬ 
ing extent. The superficial variety of this syphiloderm is distinguished 
from the deep chiefly by the extent of its ulcer, the size of its super¬ 
imposed crust, and the lighter, dull-red areola which encircles it. 

The deep variety, like the superficial, may be limited to the scalp, 
face, neck, and flexor aspects of the extremities, or it may be much 
more widely diffused. The entire surface of the body is covered with 
discrete lesions of this type in cases of unusual neglect or of profound 
cachexia. The eruption is usually of late occurrence, but in the so- 
called “galloping syphilis” of the French it maybe precocious in 
development. The lesions are at the onset nodules or tubercles, which 
become transformed into pus, and which have each a deep infiltrated 


NEW-GROWTHS. 


621 


base with a dark-brown halo. Incrustation follows, with the formation 
of a conical, roundish, or oval-shaped, blackish-brown crust, beneath 
which lies a clean-cut ulcer, the sharp edges of which are usually 
exactly roofed by the incrustation. The crust thickens by concretions 
from the foul and purulent ulcer beneath, and spreads at the periphery 
while it thickens in the centre. In this way the appearance of the 
stratified crust resembles that of an oyster-shell, a condition described 
by some authors as Rupia, a term once employed as the name of 
a disease. The ulcer, exposed after removal of the crust, is of char¬ 
acteristic syphilitic type, in its deep base, foul floor, clean-cut edges, 
and purulent secretion commingled with blood, at times attaining a 
diameter of several inches, and having a circular, reniform, or horse¬ 
shoe-shaped contour. The degree of destruction it may occasion is 
proportioned to the constitutional vigor of the subject and the treat¬ 
ment pursued. It is usually a grave, but may be a malignant exan¬ 
them, though under favorable circumstances it is easily managed; and 
may be an early, though usually it is a late symptom of the disease. 
The pigmented scars left are characteristic and indelible. 


Syphiloderma Bullosum. 

Bullse in acquired syphilis are late and relatively rare lesions. They 
are pea- to large nut-sized elevations of the epidermis, filled at first 
with a cloudy serum, which is soon transformed into pus, often mingled 
with blood. They have usually a characteristic halo about the periph¬ 
ery; are roundish or oval in contour; are usually discrete, rarely dis¬ 
seminated; and after development they produce characteristic crusts 
with underlying ulcers, identical in features with the rupioid sequels 
of large syphilitic pustules. The eruption is localized by preference 
upon the extremities, more particularly the lower extremities, and is 
indolent in its course. It is always significant of a cachectic condition 
in the subject of the disease. Its more frequent occurrence in con¬ 
genital syphilis is described later. It is to be distinguished from 
pemphigus vulgaris by its characteristic crusts and ulcers, considered 
in connection with the history and associated symptoms of lues. 


Syphiloderma Tuberculosum. 

In this eruption the lesions are usually multiple, flat, roundish, cir¬ 
cumscribed, firm, light-red to dull crimson-red nodules, beginning 
commonly as macules of a lurid hue. They vary in size from that of 
a coffee-bean to that of a small nut, and involve the entire thickness 
of the skin, often also the subcutaneous tissue. Their surfaces are 
smooth, glazed, or desquamating; and their evolution is peculiar in 
this, that they rarely exhibit apical pustulation or ulcerative degenera¬ 
tion. 

The eruption is, with few exceptions, usually limited to one or more 
regions of the body, as the forehead, the chin, the nucha, the buttocks, 


622 


DISEASES OF THE SKIN. 


and the outer surface of the thighs. It is less often disseminated than 
grouped. Occasionally there may be displayed upon the surface of 
the body but a single'tubercular lesion, the recognition of its char¬ 
acter usually demanding some skill on the part of the diagnostician. 
When occurring in groups, the typical circinate appearance of the 
syphilodermata in general may be wanting, the patches having an 
irregular boundary; but at times the circular, reniform, or horseshoe¬ 
shaped outline is quite distinct, with an enclosed area of integument, 
unaltered or the seat of atrophic changes. At times, the lesions 
assume a serpiginous character and distribution, a condition to which 
has been applied the term 


Syphiloderma Tuberculosum Serpiginosum. 

In exceptional cases serpiginous and tubercular lesions are marked 
by secondary changes. They may become covered on the surface with 
a thin yellowish crust; may lose their firmness and become soft and 
rather more lurid-red in hue, from colloid, or rarely even suppurative, 
degeneration; may vegetate luxuriantly and become the seat, especially 


Fig. 76. 



Ulcerative tubercular syphiloderm (after Keyes). 


on the scalp, of warty growths, smeared with a semipurulent secretion 
of disgusting odor (syphilis papillomatosa, syphiloderma frambesi- 
oides); or they may finally ulcerate, the superimposed crusts thickening 
in bulk, deepening into blackish and greenish shades, and covering 
typical syphilitic ex ulcerations, with characteristic edges, floor, base, 
and secretion. The degeneration in the latter case may be rapid, and 
the destruction extensive. This result is, however, of rare occurrence. 

The course of the eruption is indolent, months usually elapsing 


PLATE XI 



Tubercular Syphiloderm, Resolutive and Serpiginous. 
[From a photograph of a hospital patient.] 





NEW-GROWTHS. 


623 


before its full evolution is accomplished. In untreated cases there is 
unquestionably produced a generalized and symmetrical syphiloderm. 
It is rare, however, even in hospital and dispensary cases, to observe 
such development; the more superficial, generalized, and symmetrical 
are the lesions, the briefer, as a rule, is the interval between such an 
eruption and the date of infection. The later the lesions, the more 
apt are they to be asymmetrical, localized, and profound in their 
involvement of the deep tissues. This syphiloderm rarely appears in 
the second, more often in the third or fourth, still more rarely in the 
fifth, tenth, or fifteenth year of the disease. 

Resolution occurs by resorption, leaving in the site of the tubercles, 
according to their age, size, and contents, livid and pigmented macu- 
lations, or peculiar, pigmented, atrophic, cicatriform areas. Scars fol¬ 
lowing the ulcerative lesions are typical in color, shape, and career, 
the pigmentation of both cicatrix and areola blanching from centre to 
periphery, and leaving a delicate, dull-whitish, glazed, or slightly des¬ 
quamating membranous new-growth: ancient relics of this process 
resembling in appearance thin, small coin- and larger-sized, circular 
sheets of mica. 

The diagnosis is between lupus vulgaris, lepra, epithelioma, and 
psoriasis In lupus the age of the subject, the character of any scars 
left upon the body-surface, the chronicity of the disease, and the 
absence of a history of polymorphism, will usually point to the 
nature of the disease. The tubercles of lepra are very much more 
indolent than those of syphilis, and have a characteristic oiled or var¬ 
nished look, never the livid or dull-crimson color of syphilitic lesions. 
Set upon the forehead, the tubercles of syphilis, near the line of the 
hairs, never give the leonine aspect of those at the lower border of the 
forehead and over the eyebrow of the leper. In epithelioma the age 
of the subject and the history of the disease are always significant. 
In the early stage of epithelioma the patient is often in a condition of 
excellent general health, while the imprint of cachexia is distinct in 
tubercular syphilis of the skin. In the later stages of epithelioma the 
ulcer with everted edges and eroded, hemorrhagic floor, “ varnished ” 
by its translucent secretion, is totally different from the “ punched 
out” syphilitic ulcer with its puriform secretion and discolored crusts. 
The deep infiltration of even the desquamating tubercular syphiloderm 
will distinguish it from the circular patches of psoriasis. 


Syphiloderma Gummatosum. 

The gumma is a lesion peculiar to syphilis; no other disease exhibits 
an exactly similar feature. It is usually a late or so-called “ tertiary ” 
manifestation of the disease, and is commonly observed in the form of 
one or relatively few, subcutaneous, strictly circumscribed, firm, well- 
rounded, painless and indolent tumors or nodules which, when first 
observed, are scarcely larger than a pea. They are then covered by an 
unaltered integument and are quite movable. 

Very slowly they may, when untreated, increase in size until they 


624 


DISEASES OF THE SKIN. 


Fig. 77. 



Syphilitic gummata of head and 
face (after Jullien). 


have the dimensions of that of a marble, 
of an egg, or even of bodies of a consider¬ 
ably larger size. Sooner or later, when 
not resolved by treatment, they usually 
become attached, and the overlying skin 
becomes involved, showing by its livid, 
reddish, or purplish hue, and its hyperemic 
areola that it threatens to yield. Finally, 
at one or at several points the skin is so 
thinned as to be incapable of further re¬ 
sistance, and thus is exuded a thick sanious 
secretion the gummy character of which has 
given the lesion its name. When the in¬ 
flammation has been active its secretion 
may wholly dr partly be purulent, and in 
this case be furnished either by the con¬ 
tents of the tumor or by the peripheral 
tissue which participates in the process. 
Ulcers always result which occasionally are 
fistulous in type, roundish or oval in con- 


Fig. 78. 



Syphiloma of the vulva with gummatous changes in labia and clitoris, and languettes of anus 
accompanying stricture of the rectum. 

(From a photograph.) 












NEW-GROWTHS. 


625 


tour, with edges clean-cut, and floor purulent and extending to the 
subcutaneous tissue, tendons, aponeuroses, cartilage, or bone. Thin 
and yielding bands or bridges of undermined skin often extend between 
several such solutions of continuity, and usually melt down in the pres¬ 
ence of the destructive process* When repair is progressing, which is 
decidedly the rule as regards the ultimate result, granulations spring 
from the floor of the ulcer, the edges contract, and the gummatous 
eventually exhibits the appearance of a simple ulcer, save in the thinned 
purplish, pigmented appearance of the outlying integument. The 
scars are typical, bleaching from the centre, and they may be attached 
to periosteum or bone, though this is exceedingly rare. Consider¬ 
ing the depth of the process, the gumma of the skin is certainly, as 
a rule, succeeded by less evidence of destruction at the height of the 
process. About the neck the cicatrices may be linear in shape and 
slightly puckered. Upon the lower extremities and the trunk they are 
usually circular or oval. 

But one gumma may appear upon the person of a single individual, 
and, wheu this is the case, it will usually be found upon the leg. Half 
a dozen or more may at times coexist. In other cases hundreds form. 
Gummata may develop upon any part of the body, and when situated 
over the trunk of a nerve may become the seat of severe neuralgic 
pain. They are particularly amenable to treatment, and they may 
undergo resorption, leaving little or no trace of their former existence. 

Gummata are to be distinguished from fibrous, carcinomatous, and 
lipomatous tumors, as also from indurated and enlarged lymphatic 
ganglia. As gummata occur in very marked preponderance below 
the level of the knees, and are for the most part single or relatively 
few in such situation, they can by their position alone frequently be 
differentiated from each of the new-growths mentioned, no one of which 
occurs by preference upon the lower extremities. As they are, more¬ 
over, relatively late lesions of syphilis, a history of pre-existing symp¬ 
toms of that disease can usually be obtained. 


Erythanthema Syphiliticum. 

Under this title Bronson 1 describes a condition observed by him¬ 
self in syphilitic patients. Upon a well-defined, crimson or livid, 
erythematous surface (face, palms, soles) appeared an abundant crop 
of pea-sized vesico-pustules, which were converted later into an exud¬ 
ing, whitish, elevated, diphtheroid patch. The multiformity of the 
exanthem was characteristic. In parts it suggested the hydroa bulleux, 
of Bazin; in other parts the dermatitis herpetiformis, of Duhring. 
The fluid exudation that affected the face was not characteristic of the 
evolution of the palmar and plantar lesions. 

Later, warty, papilliform lesions appeared over the face and neck, 
somewhat resembling secreting condylomata, and surmounting, for the 
most part, a dusky-red or erythematous surface. 


1 Medical Record, September 4, 1886, p. 253. 

40 


626 


DISEASES OF THE SKIN. 


This author regarded the exanthem as primarily a syphilitic product, 
but not pathologically or etiologically a true syphiloderm. Its origin 
was possibly similar to that of the angioneurotic, trophoneurotic, or 
reflex phenomena of skin disorders in general. 


Syphilis of the Mucous Surfaces. 

The lesions of syphilis involving the mucous membranes, found 
chiefly in the mouth, but exhibited, also, in both acquired and infantile 
disease, over the nasal, aural, vaginal, anal, and balano-preputial sur¬ 
faces, are strictly allied to the similar symptoms in the skin. The 
differences are due to maceration of the involved surface, to the func¬ 
tions of the organs chiefly implicated, to contact, and to apposition of 
contiguous parts. 

There is, hence, every grade of disorder from hyperemia to inflam¬ 
mation; and the results of the latter are both ulceration and cicatriza¬ 
tion, each result being subject to the special modifications due to the 
syphilitic process (gummatous deposits, infiltrations, etc.). 

In the purely hyperemic forms there is, usually at the moment of, 
or soon after the outbreak of, general syphilis, a pharyngeal or a phar- 
yngo-nasal blush, spreading symmetrically or irregularly over the parts, 
accompanied often by engorgement of the tonsils, especially in persons 
previously subject to disorders of the same region due to other causes 
(catarrh, follicular tonsillitis, etc.). There is then pain on swallowing; 
and complications may arise, producing laryngeal hoarseness, cough, 
dyspnea, aphonia, nasal discharges, crusts blocking up the passages 
(especially in inherited disease), and impeded transmission of air 
through the nares. Similar conditions may be observed about the os 
uteri, the perianal region, and other of the sites named above. This 
may or may not be the precursor of the severer complications—mucous 
patches, ulcers, and other symptoms of syphilis of mucous surfaces. 

Mucous Patches (Plaques inuqueuses, Schleiinhautpapeln,Condylo- 
mata, Feigwarze) are merely syphilitic papules occurring in moist situ¬ 
ations, flattened by reason of the apposition of affected surfaces and 
by contacts necessitated by the functions of the parts involved. They 
form upon all mucous surfaces, but are nowhere better studied than in 
the mouth, where they are the most annoying and the most persistent 
symptoms of syphilis, complicating both the early and the later stages 
of the disease. 

The patches are roundish or oval, tumid, flattened, or very slightly 
depressed, pale-rosy or whitish spots, moistened by mucus, either devel¬ 
oping as such or resulting from hyperemic plaques of the sort described 
above, or dispersed among or upon the latter. They often resemble 
the patches producer! on the mucous membrane by pencilling the latter 
with a crayon of the nitrate of silver. When carefully inspected, 
many of them exhibit a loosened and partially detached film of mem¬ 
brane covering the tissue, beneath which a reddish, raw-looking surface 
appears. They are seen not merely upon strictly mucous surfaces, but 


NEW-GROWTHS. 


627 


develop also on the verge of the latter (mouth, anus, scrotum), and 
even on moistened cutaneous surfaces—the edges of the nails in infants, 
and in persons whose hands are often macerated, between the toes, in 
the vulvo-crural angles, etc. The condyloma is by many writers 
described separately, but the older authorities were by no means in 
error when using, as appears above, the term “ condyloma” for both 
the mucous patch and the flattened creamy-looking secreting papules 
seen often about the anus and the vulva of the subjects of syphilis, 
particularly those of a tender age; for the condyloma is actually a 
flattened syphilitic papule, as is the mucous patch, the external appear¬ 
ances of which are chiefly the result of its site and surroundings. 

The secretions of these lesions are at times very offensive in odor, 
especially about the anogenital regions, but also about the mouth and 
the nose (infants, the filthy, and the neglected). They may become 
fissured (edges of the tongue, tonsils, vagina), may ulcerate deeply, 
may be the seat of vegetations (papilloma, so-called “ esthiomene of 
the vulva,” etc.), and, in general, may furnish a highly contagious 
secretion. It is probable that mucous lesions are more responsible for 
the transmission of contact-syphilis than are chancres. 

Mucous lesions are to be distinguished with care from simple aph¬ 
thous patches # in the mouth the result of indigestion or local disturb¬ 
ances; also from smokers’ patches (leucoplakia buccalis, “psoriasis 
linguae,” leucopla&ie). In external features these patches may some¬ 
what resemble one another, but in only one affection, syphilis, are there 
other signs of infectious disease. The chief points of difference are: 
singleness, for the most part, of aphthous sores, and often exquisite 
tenderness; multiplicity, as a rule, of mucous patches, and much less 
soreness, though when ulcerated the soreness may be a conspicuous 
feature. Linear streaks and bands (often quite insensitive) of leuco- 
plasic patches are especially found along the gums, on the lines of the 
inner cheek representing contact with the approximated upper and 
lower teeth, and in the pocket posterior to the wisdom tooth. 

Scaly Patches, described by most authors separately, are not true 
mucous lesions of syphilis. They occur not rarely in syphilitic sub¬ 
jects as flattish, smooth, bluish-white, or lead-white, firm, slightly 
indurated, and roundish or highly irregular plaques They are visible 
on the dorsum of the tongue, on the mucous lining of the cheeks, and 
at the angles of the mouth, where they are situated often in part on 
the mucous surface and in part on the skin of the lip. The thickened 
epidermis is at times covered with adherent, not readily removed, scales 
between which fissures form, and the patch, at first almost insensitive, 
becomes exceedingly tender and painful. 

These patches are for the most part of the order described above, 
that is, leucoplasic, due chiefly to irritation of the mucous surfaces by 
tobacco-smoke, yet occurring in syphilitic subjects, as they are pre¬ 
ceded often by typical mucous patches. They are almost exclusively 
seen in men. They are also rarely encountered in inherited syphilis. 
In the distinction sought to be made between the specific and the non¬ 
specific form attention is called to the occurrence in the latter class of 


628 


DISEASES OF THE SKIN . 


hard, uneven, and considerably thickened patches, which occasionally 
proliferate, and which, extending to some depth, are eventually trans¬ 
formed into epitheliomatous lesions. 

Gummatous infiltrations of mucous membranes (“ sclerosis of the 
tongue /* 9 of Fournier) occur in both circumscribed and diffused forms, 
superficial and deep. In the diffuse superficial forms both the mucous 
and submucous tissues are involved in a firm thickening, best studied 
on the surface of the tongue, which then becomes to the view polished 
and smooth, at times appearing as if covered with a thin translucent 
varnish. Patients exhibiting this condition will often describe a sub¬ 
jective sensation of “slipperiness.” These thickenings may involve 
the deeper structures by every gradation, producing eventually lobu- 
lated masses with intervening fissures, tender, raw, and excoriated. 
The general face of the tongue is then, as a rule, covered with a partic¬ 
ularly foul, dirty-grayish coat, and it is occasionally notched at the 
edge with deep ulcers. At times the tongue is mottled, with patches 
of redness alternating with the yellowish-white of the deposit on the 
surface of the membrane. 

The deeper gummata involve the body of the tongue, and they are 
felt as submucous, diffuse or circumscribed, dense thickenings (usually 
tolerably well defined), which soften, ulcerate, and leave exposed to 
view extensive losses of substance. The floors of these excoriations are 
deep ulcers, indurated, sloughy, and with membranous shreds over the 
surface. The fissures of the sides of the tongue described above may 
here also produce deeply ulcerated notches in the substance of this 
organ. It is surprising how greatly deformities of this class are 
relieved after cicatrization, even when considerable loss of tissue has 
resulted. 

The local treatment of all syphilitic lesions of the mucous surfaces 
is both hygienic and medicinal. All catarrhal conditions of adjacent 
mucous surfaces (vagina, nasal cavity) require attention. The surfaces 
should be kept free from all irritation (tobacco in all forms, iced and 
hot articles of food and drink, condiments, acetous and alcoholic fluids 
in the mouth; coitus and irritating injections of vulva; napkins that 
have been soiled over the anogenital region of infants). Locally, the 
nitrate-of-sil ver crayon, used as a pencil, is effective in the management 
of most patches, applied once daily, or every second or third day 
Occasionally stronger caustics are required, such as acid nitrate of 
mercury, or nitric acid. Mouth-washes containing chlorate of potash, 
myrrh, and honey; 15 to 20 drops in water of Bellamy’s iodized phenol; 
very dilute lotions of tincture of iron, or dilute muriatic acid, a tea¬ 
spoonful to a pint of sweetened water; and carbolated lotions, are 
required in different cases. In very great soreness and tenderness of 
the mouth only the blandest applications are tolerated, such as thin 
flaxseed-tea, oatmeal gruel as a wash, and gum-acacia water. A few 
formulae are appended: 


H.—Potass, chlorat, 

3j'; 

4 

Mel. despumat., \ 
Myrrh, tinct., j 

aa ^ss; 

16 

Aq. dest. ad. 


200 


Sig. —A teaspoonful in water as a wash for the mouth and throat. 


M. 



NEW-GROWTHS. 


629 


J&.—Acid, carbolic., 
Iodin. tinct., \ 
Glycerin., / 

Spts. vin. rectif., 
Aq. dest. ad., 

Sig.—Fifteen to twenty 




3 ij; 8 

fSjJ 32 

drops as a lotion in water for the mouth. 


M. 


K.—Potass, chlorat., gj; 4| 

Aq. menth. piperit., aa ^ vj; 200| M. 

Sig.—Gargle and wash for the mouth; to be used slightly diluted. 


The internal management of these cases is that demanded by the 
general condition of the system and the stage of the disease, as ex¬ 
plained in the concluding pages of this chapter. 


Syphiloderma Infantile, Acquisitum et Hereditarium. 

Syphilis may be acquired by the infant child at any period after birth, 
as, for example, by immediate contagion from the nipple of the nurse, 
or mediately, as by the use of utensils smeared with a secretion capable 
of transmitting the disease. Such acquired infantile disease displays, 
for the most part, the symptoms observed in adult years, except that 
the delicate and tender skin at this early period of life is apt to exhibit 
the moist and secreting lesions of syphilis. The mucous patch, the pus¬ 
tule, and the condyloma are here more common than the papulo-squa- 
mous symptoms of the adult. Some influence is also exerted upon the 
disease by the dress, habits of life, and mode of obtaining nutriment, 
which are conditioned upon the helplessness of the young child. In 
this way the soiled napkin over the anogenital region, the warm cov¬ 
ering of, and free diaphoresis from, the general surface of the skin, and 
the frequent contacts of the lips with the nipple, suffice to determine 
in special regions particular local expressions of the constitutional vice. 
The acquired is much less grave in character and portent than the 
inherited form of the disease. 

Hereditary syphilis, which may first be displayed in infancy or in 
early adult years, is always strictly transmitted by inheritance from 
one or both parents. The consideration of the disease in these pages 
being limited to its cutaneous manifestations, it is first to be noted that 
the infected foetus may prematurely be expelled with cutaneous symp¬ 
toms displayed upon its body-surface. 

This condition generally argues in favor, either of intense syphilis 
in one or both progenitors, or, more commonly, of relatively recent 
infection of both. Under these circumstances there are usually evi¬ 
dences of the death of the foetus at some date prior to its expulsion, 
the skin being macerated and the epidermis raised from the corium in 
few or many bullous lesions, beneath which the derma exhibits a livid 
reddish or a purplish hue. 

When the infant is born with a clean skin, it may be shrivelled and 
emaciated, or be fat and presenting the appearance of sound health. 
Soon after birth, however, cutaneous manifestations appear, usually 
not before the conclusion of the first month, more commonly during 



630 


DISEASES OF THE SKIN. 


the second, rarely after the third and the fourth. The earlier the 
date of such explosion, the more intense, as a rule, is the evidence of 
the disorder. The first symptoms displayed are significant of visceral 
involvement, and are, in brief, those of marasmus. Emaciation pro¬ 
gresses rapidly; the skin seems stretched unnaturally over the facial 
bones; the expression is that of physical distress; the cry becomes a 
fretful moan; the integument loses entirely the rosy hue of the healthy 
infant, and acquires instead a sallow or muddy tint; and very peculiar 
wrinkles or puckered lines radiate from the angles of the lips. Few 
observers have failed to notice the resemblance which then exists be¬ 
tween the faces of these emaciated little creatures and those of the aged 
of both sexes. 

In this complexus of symptoms, however, there is absolutely nothing 
characteristic of syphilis as distinguished from other wasting diseases 
of infancy. Chronic tubercular meningitis and the gastro-intestinal 
disorders of infancy in their extreme expression furnish a precisely 
similar picture. This is natural enough, since all depend alike upon a 
similar cause, failure of proper performance of function on the part of 
the viscera in consequence of pathological alterations. 

The coryza of the syphilitic infant, however, is soon declared, and 
speedily gives a clue to the nature of the morbid process. The dis¬ 
charge from the nares (at first serous, later purulent) desiccates suffi¬ 
ciently to obstruct the nasal passages or, in consequence of the tumid 
condition of the membrane lining the passages, is prevented from 
escaping. Often this discharge is furnished by a specific rhinitis 
chiefly invading the Schneiderian membrane. At times crusts accu¬ 
mulate externally about the nasal orifices, and they are seen to be 
similar to those which are apt to form also at the angles of the 
mouth. In this way the characteristic “snuffles” of the syphilitic 
infant are induced, in consequence of which it is obliged when nurs¬ 
ing to release the nipple from its mouth in order to respire, an act often 
accompanied by a hoarse cry. The breathing of the syphilitic infant, 
even when asleep, or awake and undisturbed, is often sufficient to 
arouse a suspicion as to the nature of the disease from which it is suffer¬ 
ing. The mouth, the larynx, the vulva, and the anus are often the 
seat of similar lesions, the development of which into an obstructive 
tumefaction secreting more or less profusely, or into moist condylo- 
mata, will largely depend upon the seat and surroundings of the lesion. 

The cutaneous symptoms of inherited syphilis are macular, papular, 
pustular, bullous, or furuncular, two or more of them being at times com¬ 
mingled, attesting thus the identity of the disease with the polymorphic 
acquired forms of maturer years. Macules are early to appear upon 
the trunk, the face, and the extremities, usually of a livid reddish hue, 
commingled with papules, and indeed often occurring as the first mani¬ 
festation of the papules. They are irregular as to shape, and though 
occasionally pinkish, discrete, circinate, and coffee-bean-sized, often 
produce a diffuse, coppery-red, or violaceous, glazed, or moist and 
secreting surface, affecting an entire region, as the neck, the trunk, or 
the thighs and the genitalia. Deep excoriations and even fissures 
occasionally form in these extensive patches, and the secretions may 


NEW-GROWTHS. 


631 


incrust them irregularly, the general aspect of the patch somewhat sug¬ 
gesting an eczematous condition, yet remarkably differing from it in 
color. 

In hereditary, as in acquired syphilis, the type of all the eruptive 
symptoms is to be sought in the papules which may spring from the 
macules described above, and develop into pustules, bullae, or condy¬ 
lomata; and, in the former case, dull-red or violaceous papules of lentic¬ 
ular size, occur either in asymmetrical or symmetrical arrangement, 
being discrete or agglomerated in patches of infiltration. These pap* 
ules may, especially upon the buttocks, scale at the apex; or, particu¬ 
larly upon the palms and soles, may constitute by fusion a thickened 
desquamating epidermal patch; or, commonly about the anogenital 
region, the interdigital spaces, the axillae, and face, may become moist, 
and secrete a puriform mucus. By vegetation or by hypertrophy, 
they develop into flat or fissured condylomata, smeared with an offen¬ 
sive, yellowish or yellowish-white discharge; and vary in size from 
that of a coin to a lesion an inch or more in diameter, with correspond¬ 
ing variation in the degree of their elevation from the affected surface. 
Condylomata may be very few or very numerous. Sometimes a child 
will appear to be well-nigh covered with large, moist, secreting papules. 
Papulo-condylomata may deeply ulcerate and crust. It should be re¬ 
membered, in studying these symptoms, that they are those of a ca¬ 
chectic infant affected with a grave disease. Death often interrupts the 
sequence of the manifestations above described. This event is usually 
preceded by the signs of apparent amelioration, shrinkage of hyper¬ 
trophic growths, and decoloration of hyperemic lesions and patches. 
Of the other cutaneous symptoms of hereditary syphilis, vesicles are 
the rarest; the smaller, occasionally seen, have a conical apex, with 
serous contents, are closely set together about the lips, and spring from 
a violaceous infiltrated patch. The resulting crusts never have the 
reddish-yellow tint of those observed in eczema, nor, after rupture, are 
they followed by serous oozing from a wounded epidermis. The larger 
lesions of this sort are usually transformtions of papules which rapidly 
assume a pustular phase. 

Pustular eruptions, in this form of syphilis, may be discrete or be 
confluent, localized or generalized. They are particularly apt to occur 
in groups about the mucous outlets, with maculo-papular lesions devel¬ 
oped elsewhere, and they may result in ulceration, often after develop¬ 
ment into bulke with pustular or sanious contents. The resulting crusts 
are bulky and dark-colored, and, especially upon the face, disfiguring. 
The subjective sensations are probably insignificant, since the child 
does not attempt to tear the affected surface, as in pustular eczema. 
The cachectic condition of the little patient is usually pronounced when 
these lesions are large and numerous. They may be seen in typical 
development by the side of the nail, occasionally involving the matrix, 
and producing, in this situation, considerable swelling of the digit, 
with an ulcerative sequel which commonly results in distortion or an 
ultimate loss, of the nail-substance. Onychia, however, may result from 
perverted nutrition of the part, with increase in the friability of the 
nail-substance, loss of lustre, assumption of a dirty-grayish hue, and 


632 


DISEASES OF THE SKIN. 


phalangeal oedema. These changes are analogous to those resulting in 
loss of the hair where the follicles have imperfectly been nourished. 

The furuncles which form in other cases are either exaggerated man¬ 
ifestations of the same pyogenic tendency in the skin of the infant, a 
complication common to syphilitic and other cachectic conditions in 
young children, or are the result of infection with pus-cocci, a more 
frequent cause. These furuncles may be few or be numerous, and they 
are chiefly characterized by their indolence, the absence of laudable 
pus in their contents, the ulcerative condition left after their evacua¬ 
tion, and the bluish or purplish condition of the integument which 
surrounds their edges. 

Bullae in hereditary syphilis are early or late manifestations of the 
disease, and they may be represented by a single lesion on the palms or 
soles (the site of their predilection), or they may constitute a symmetrical 
generalized efflorescence. Bullae should be regarded as evidences of 
a grave form of the disease, being often the precursors of a fatal issue, 
as indicating a feeble resistance on the part of the epidermis to the 
fluid exudate furnished from the corium beneath. In severe cases the 
bullae are ill-developed, and the integument will be seen to be marked 
here and there by small coin-sized and larger disks or plaques of macer¬ 
ated epidermis, separated from the derma by a thin film of serous, 
sanious, or purulent fluid, in quantity insufficient to raise the roof 
above the general level of the integument. When fully developed, 
they may be conical, rounded, flat, or quite flaccid, and be surrounded 
by an infiltrated border of dark-reddish or violaceous hue. Their color 
varies with the color of their contents. Their subsequent career is 
concluded by shallow or by deep ulceration, the base of each secreting 
a sanious discharge. Crusts may form if the patient survives. A 
fatal termination of the disease is usually announced by their flatten¬ 
ing or collapse. They may be commingled with pustules, maculo- 
papules, condylomata, and mucous patches of the anus, the mouth, 
and the nares, but they are somewhat different from the other lesions 
described, in that they may constitute a uniform efflorescence, no other 
cutaneous symptoms being manifested. The uniformity is due to the 
fact that bullae represent the state of feeblest resistance in the epidermis, 
the fluid exudate of exceedingly low grade mechanically separating the 
rete from the tissues beneath. 

Tubercles and subcutaneous gummata may develop in hereditary 
syphilis, but only as late manifestations of the disease, one or more 
years elapsing before their appearance. Their behavior is scarcely 
different from that of those observed in the acquired forms, although 
the destruction wrought by their degeneration in very late manifesta¬ 
tions may be of the most intractable type. Usually there is a history 
of preceding parental or inherited disease, and coincident symptoms 
or sequels of such disease, in altered teeth (as described by Hutchin¬ 
son, of London), in an ancient keratitis, or in a hopeless form of 
surdity. 

Mucous patches are very constant symptoms of the disease, and they 
represent papules of the mucous membrane, that differ from those seen 
in the skin only because they are moistened, macerated, and flattened 


NEW-GROWTHS. 


633 


by juxtaposition of neighboring tissues. They are surrounded usually 
by a lurid halo, and they may have the pearly whiteness always seen 
when the epidermis of mucous membrane is wholly or partly detached 
from the corium; or they may lose this protecting disk in shreds or 
patches, and show, beneath, an engorged, or ulcerated and secreting 
tissue. They may be isolated or be broadly confluent, and be oval, 
circular, or decidedly linear in shape, the last-named appearance being 
characteristic of those patches existing at the angles of the mouth. 
Mucous patches are to be recognized as distinct from both the parasitic 
and non parasitic forms of simple stomatitis or thrush, the parasitic 
form being due to the presence of the oidium albican*. In both of 
the non-syphilitic disorders the mouth of the child will be seen to be 
very generally, uniformly, and symmetrically involved, the circum¬ 
scribed patches being distinctly discrete and resembling in color soft 
whitish or yellowish flocculi of curdled milk. 

The diagnosis is always greatly aided by noticing the well-nigh con¬ 
stant occurrence of patches just at the angles of the syphilitic mouth, 
which has also the seamed and puckered appearance described above. 
Snuffles, syphilodermata, and marked cachexia, when established, will 
leave little doubt as to the nature of the malady. 

The future of the infant affected with hereditary syphilis is not 
always as dark as might be gathered from what has preceded. In 
this, as in the acquired form of the disease, benignancy may be a con¬ 
spicuous feature of the entire process The evolution of the disease 
may be tardy; its symptoms be few and unimportant; its amenability 
to judicious treatment speedily be demonstrated. Still, the fact remains 
that the disease when inherited is far graver than when acquired, the 
victim of inheritance entering the world with its viscera and bones 
subject to profound pathological alterations. 

Etiology. Syphilis, in the course of which appear the syphiloder¬ 
mata, is produced invariably by either accidental or intentional infec¬ 
tion, or by the obscure influences of heredity. The methods of trans¬ 
mission may be immediate, as in sexual congress, in kissing, and in 
nursing at the nipple, by which act the child may infect the nurse with 
the secretion of the mucous patches in its mouth, or it may, instead, 
receive the disease from the excoriations on the breast of the nurse. The 
disorder may also result from the medium of utensils charged with an 
infectious secretion, such as the needles of the tattooer wet with saliva 
commingled with diseased mucus, or the lancet of the vaccinator cov¬ 
ered with an intoxicated blood. Generally it may be said that all the 
discharging and moist syphilodermata are sources of danger to a sound 
individual, both in the acquired and inherited forms of the disease. 

By these and other similar methods persons of both sexes and all 
ages may become infected. 

However begotten, the syphilodermata are yet not excluded from 
subjection to the long list of external irritants which may in turn 
annoy the skin. The influence of a hot bath, or the excitement and 
perspiration of the dance, will often invite to the surface a macular 
syphilide which might otherwise be less fully developed; friction, as 


634 


DISEASES OF THE SKIN . 


by the hatband over the forehead, the cuff at the wrist, and the shoe 
over the foot, demonstrates its influence by daily examples of deter¬ 
mination of the morbid process to special localities. In the trades 
the hands of the syphilitic laborer betray unmistakable evidences of 
the irritative effect of harsh contacts upon the skin; the same may be 
said of filth, such as the feces on the napkin of the infant that 
frequently provoke condylomata in the anal region. It is a mistake 
to suppose that syphilis, aud syphilis only, is responsible for the 
exanthemata of that disease in all shades, grades, and situations. 
Soap and water are as efficient in preserving the skin of the syph¬ 
ilitic as of the sound; and the infected tobacco-chewer pays a price 
for his nauseous habit. Poverty, misery, and wilful neglect, or ignor¬ 
ance of the laws of hygiene, are responsible for a long and lengthen¬ 
ing list of the complications of the disease. 

Pathology. The pathological anatomy of syphilis and the syphilo- 
dermata has carefully been studied by a large number of observers, 
including Virchow, Wagner, Cornil and Ranvier, Neumann, Auspitz, 
and Biesiadecki. It must be admitted that the result of their studies, 
even though it present a fair picture of the pathological appearances 
exhibited by the several lesions subjected to examination, is yet far 
from furnishing au explanation of the nature and peculiarly capricious 
career of the disease. Under the microscope it can clearly be deter¬ 
mined merely that the recognized processes of hyperemia, exudation, 
hypertrophy, new-growth, and degeneration (caseous, fatty, amyloid, 
atrophic, and necrotic) occur in syphilis as in some other disorders 
with cutaneous lesions; that the specific character of the disease is uot 
betrayed by any specificity of elements or of their arrangement; and 
yet that every pathological process of syphilis bears the imprint of the 
malady whose influence it acknowledges. Here is a lesson certainly 
confirmed by clinical facts. With the possible exception of the gumma, 
there are no cutaneous lesions which are peculiar to syphilis, and yet 
there are certain modes of behavior by which each lesiou, when care¬ 
fully studied, betrays its ideutity. It is then by its modality rather 
than by any essential characters that the syphilitic process is to be 
differentiated from all others. 

The papule, the tubercle, and the gumma may be regarded as typical 
pathological developments of the disease, as they certainly constitute 
the basis of its common and important cutaneous manifestations. One 
of them, the gumma, may indeed develop in any organ of the body 
other than the skin. Under the microscope these lesions are seen to be 
made up of a new-growth whose numerous, small, rounded, or spindle- 
shaped elements, whether derived from connective tissue or from out- 
wandered leucocytes, or both, and whether found, as they may be, in 
the rete, the corium, or the subcutaneous tissue, very probably repre¬ 
sent transformation of protoplasm previously existing, or resulting from 
embryonal metamorphosis of such pre-existing elements. Kaposi well 
summarizes the chief peculiarities of this new-growth, as showing : 
first, that its elements are distinctly circumscribed and homogeneous, 
differing, the minutest papule from the largest tubercle, only in respect 
to volume; second, that they are inapt for permanent organization, but 


NEW-GROWTHS. 


635 


retrograde and disappear either by resorption or by suppuration; third, 
that they are remarkable for their tendency to coincident evolution and 
involution, usually in a centrifugal directicn, the younger peripheral 
portions presenting the characters of recent infiltration, while the more 
ancient, situated at the pathological centre, are earliest to disappear. 

This new-growth naturally plays a more important part in some 
lesions than in others. Scarcely discernible in the hyperemia of the 
macular lesions and well-defined in the papule and its modifications 
(the tubercle, the condyloma, and the forming gumma), it is repre¬ 
sented in the vesicle, pustule, bulla, and degenerating gumma by either 
a fluid exudate composed of granular, cloudy, and nucleated elements, 
or by a soft, succulent, grayish, or grayish-red homogeneous mass 
yielding a scanty juice, and not yet completely transformed by degen¬ 
eration to the fluid condition. Beneath and about any of these last- 
named lesions, the circumscribed new-growth may lay a foundation 
or erect a wall which unmistakably asserts the unity of all such pro¬ 
cesses. 

Viewed comprehensively, the multiform development of the syph¬ 
ilitic new-growth is seen to be incontestably more rapid of evolution 
and involution than, in their average career, are all the neoplasmata. 
Sarcoma alone competes with it in this regard. Lepra, lupus erythe¬ 
matosus, lupus vulgaris, keloid, xanthoma, and the large majority of 
all forms of epithelioma outlive, as a rule, generations of syphiloder- 
mata. This relative rapidity of career has entailed upon the disease 
its possibilities in the direction both of benignancy and of malignancy. 
Whether it destroy life, or so slightly interfere with health as well- 
nigh to pass unnoticed, in either event the total period of its activity 
is relatively brief. 

The demonstration of the bacillary origin of syphilis, as already 
stated, is not yet complete. Every fact in its history, however, and the 
recent advances in the discovery of the part played by micro-organ¬ 
isms in the production of other diseases, point unmistakably to a para¬ 
sitic origin of syphilis. There is reasonable ground for believing to-day 
that the disease belongs to the class of infectious granulomata, even 
if the conclusions of Lustgarten and Doutrelepont be not confirmed 
by further experiment, the crucial test being a series of productions of 
syphilis in unmistakably sound individuals by infection with a product 
of bacilli obtained by cultivation. 

Lustgarten first hardened sections of syphilitic lesions (initial scle¬ 
roses, papules, and gummata) in absolute alcohol and colored them in 
a solution of gentian-violet for from twelve to twenty-four hours at 
the ordinary temperature, and then for two hours at 104° F. The 
sections were decolorized by washing in absolute alcohol, in a 1J per 
cent, aqueous solution of the permanganate of potassium and in an 
aqueous solution of pure sulphurous acid. 

It is claimed that by the special method thus employed character¬ 
istic organisms were always recognized in syphilitic and never in non- 
syphilitic lesions. The bacilli were never free, but were always enclosed 
in cells of ameboid movement, resembling lymphoid cells. These 
bodies were straight, curved, or irregularly bent in rod-like forms, 


636 


DISEASES OF THE SKIN. 


averaging from three and one-half to four and three-tenths of a micro- 
millimetre in thickness. Under objectives of low power they presented 
a uniform smoothness with occasional terminal bulbous expansions. 
The surface of the bacillus, however, viewed under a homogeneous 
immersion-lens, appeared irregularly undulating and slightly notched, 
the bacillus or rod-like appearance remaining distinct. Within each 
bacillus, separated from each other by spaces of equal length, were 
from two to four bright colorless spores. 

More recently, however, micro-organisms, similar to those believed 
to be the sources of syphilis, have been discovered in the smegma 
preputii and other secretions obtained from the genital organs of non- 
inf ected persons of both sexes, thus confirming the belief that the 
specific bacterium of the disease has not been recognized. 

Diagnosis. The syphilodermata are to be distinguished from all 
other cutaueous eruptions by their general characteristics and by the 
features peculiar to each lesion. It must not be forgotten, however, 
that these lesions are not essentially different in character from all 
others, but are to be recognized with ease or with difficulty, according 
as they do or do not betray the the syphilitic expression. No one, how¬ 
ever expert in diagnosis, can always trust himself to recognize these 
special features by a study only of the eruption, at a given moment of 
time. Neither in respect to color, form, size, situation, disposition, or 
other peculiarity, do the syphilodermata exhibit an absolute difference 
from non-syphilitic, affections of the skin. It is, therefore, requisite 
in every case to investigate in the fullest manner.the history of the 
disease, of all prior skin-lesions, of a primary sclerosis (when this 
can be obtained), of adenopathy, miscarriages, abortions, and disorders 
affecting other organs of the body, as the bones, the viscera, the organs 
of sense, and the mucous surfaces. Often a single extra-cutaneous 
fact will be a valuable aid in establishing the diagnosis of syphilis. 
An “ eczematous ” infant, with snuffles and a hoarse cry, has been 
treated in vain by many a physician, otherwise capable of making a 
diagnosis, who might have been given a clue to the nature of the dis¬ 
ease from which the child was suffering, if he had taken the pains to 
inspect the anus and question the father in private. 

It is very necessary in this connection to lay stress upon the well- 
known fact that every syphilitic patient with a disease of the skin does 
not necessarily exhibit syphilodermata. The course of the disease in 
many cases is so protracted that patients have ample opportunities to 
contract other disorders, and their number is larger than is commonly 
supposed to be the case. They suffer most often from the medicamen- 
tous eruptions, especially those induced by the ingestion of iodid of 
potassium (cf. the chapter on Dermatitis Medicamentosa: Drug Erup¬ 
tion from Salts of Iodin); they are, like other men and women, bitten 
by bugs and lice; and they suffer from eczema, acne, psoriasis, and other 
non-venereal disorders. This common susceptibility is less true possibly 
of the innocent victims of the disease than of those guilty of sexual 
excesses in and out of the married state, many of the unmarried lead¬ 
ing the most disordered lives, and exposing themselves to the ordinary 
causes of disease to a degree not noted in other persons. 


NE W- GROW THS. 


637 


It is always necessary, therefore, in making a diagnosis in a case 
supposed to be syphilitic, first, to determine ab origine the fact of 
syphilis, and, if that fact cannot indubitably be determined, to be 
careful that the statements of the patient are not allowed to bias the 
judgment in pronounciug upon any eruption present; second, suppos¬ 
ing that such a fact is established by clinical proofs without reserve, 
to determine whether the eruption present is produced by the existing 
syphilis or some other externally or internally operating cause; and if 
this last be determined, to be careful in eliminating the syphilitic influ¬ 
ence from its operation. 

Ignored syphilis is usually severe; but it is without avail that dis¬ 
orders of a different character are treated by the methods useful in 
syphilis. Thousands are annually thus mistreated who might have 
been spared such a calamity. The frequent occurrence, after a suspi¬ 
cious exposure, of a balanitis, of an attack of progenital herpes, of 
uninfected excoriations, of blennorrhagic discharges, and even the ap¬ 
pearance of molluscous tumors, warts, or parasitic cutaneous disorders 
upon the genital region, is a source of alarm and of fruitful error to 
the many rather than to the few. 

The diagnostician none the less must ever be on the alert to recog¬ 
nize the symptoms of the disease in those who least suspect it. Thus, 
married women complaining of a “ humor of the blood,” men who 
have been u overheated and broken out with a rash, ’ ’ and a long list 
of patients exhibiting upon their persons the symptoms of “ salt 
rheum,” “ tetter,” u scrofulous ulcers,” and “ erysipelas” are those 
whose speedy relief will depend upon the skill of the practitioner in 
recognizing exactly the precise nature of the malady. 

The diagnosis of syphilitic lesions of the skin is a matter of the 
very greatest importance, inasmuch as the health, comfort, mental 
happiness, and domestic relations of thousands of men and women 
annually depend upon it alone. An error in either direction may 
involve the most serious consequences to both physician and patient. 
He is but poorly qualified to discharge the important duties of a gen¬ 
eral practitioner of medicine who has not carefully trained himself 
to establish the truth in these cases, irrespective of the diagnosis of the 
patient and of all others who may have been consulted. 

Treatment. The syphilodermata are to be treated by topical appli¬ 
cations intended to hasten their disappearance or involution; but as 
local manifestations of a constitutional disease, their management is 
largely that which looks to the relief of the latter. 

The treatment of syphilis, in the pages which follow, will be de¬ 
scribed in outline, so far as it relates to the relief of the cutaneous 
lesions and of the systemic condition. The important modifications 
of therapy that are required in the management of syphilis of the 
osseous and the nervous system, of the respiratory, gastro-intestinal, 
and other organs, it is scarcely necessary to remark, are fully described 
in the standard treatise specially devoted to this subject. Among them 
may be named, as of American authorship, the works of Taylor , 1 of 


1 The Pathology and Treatment of Venereal Diseases, Philadelphia, 1895. 


638 


DISEASES OF THE SKIN . 


Van Buren and Keyes , 1 of Morrow , 2 of E. L. Keyes , 3 and of Hyde 
and Montgomery . 4 Of those more or less recently published abroad 
may be named the standard treatises of Laneereaux , 5 of Jullien , 6 of 
Fournier , 7 of Diday and Djyon , 8 of Zeissl , 9 and of Mauriac . 10 

The first and often the most important consideration for the practi¬ 
tioner who is in face of a syphilitic patient is the care of that patient’s 
general health. Simple and natural as it may be to set down such an 
injunction in this connection, its importance rests upon the fact that it 
is too often neglected. Patient and physician respectively are often 
hurried into the precipitate ordering and swallowing of specific drugs, 
without regard to other as important details. 

It is well to hand to the patient, at the outset of all treatment for 
syphilis, a slip of paper on which are printed in concise and simple 
terms a set of rules to be observed during the continuance of the dis¬ 
ease. For physicians who do not take similar precautions it is 
advisable to enter rather fully into the explanation of certain details 
which the patient should be made to understand. 

He or she, if an adult, should, as a rule, be informed of the serious 
nature of the disease recognized, since every infected patient has an 
interest in knowing this fact, and its important bearing upon his or 
her relations to the uninfected. To every such patient, with the assur¬ 
ance that the disease is often benign, and productive of little discom¬ 
fort aud in any case is curable, it should be stated that the affection 
is contagious, and capable of transmission to sound persons by physical 
contacts of various characters. The patient should be instructed as to 
the nutritious character of the diet he should select, and should be 
informed that an increase in body-weight while subjected to treatment 
is decidedly favorable in the matter of prognosis; that the starving 
and sweating processes so highly esteemed by the charlatan and the 
advocate of the virtues of the waters of certain resorts are relics of 
antiquity, as useless in fact as they are frequent sources of peril. 

The bathing of the body is a matter of importance. Hot, Turkish, 
and Russian baths, as a rule, are to be interdicted, inasmuch as they 
tend to invite cutaneous hyperemia, and thus to favor the occurrence 
of eruptions. Cool or tepid baths are to be employed sufficiently often 
for the purpose of cleanliness, aud by the sponge rather than by immer¬ 
sion. Dry friction daily of the surface of the body may be ordered 
with advantage where the skin is still sound. The teeth, the mouth, 
and gums require constant care. The use of the tooth-brush with cool 
water twice daily is a matter of importance, and the brushing should 
be preceded for a time, when the gums at the outset are in a tender, 
fungous, or hemorrhagic state, by gentle friction of the teeth with the 

1 A Practical Treatise on the Surgical Diseases of the Genito-urinary Organs, including Syphilis, 
New York, 1874. 

2 System of Genito urinary Dis., Syph. and Derm., New York, 1893 (3 vols.). 

3 Surgical Diseases of the Genito-urinary Organs, including Syphilis, New York, 1888. 

4 Manual of Syphilis and the Venereal Diseases, Philadelphia, 1895. 

5 Traite historique et pratique sur la Syphilis, Paris, 1874. 

6 Traite pratique des Maladies V6neriennes, Paris, .886. 

7 Lefons sur la Syphilis, etc., Paris, 1873. La Syph. Hered. tard., 1886. Traitementde la Syphilis, 
Paris. 1895. Les chancres Extra-genitaux, Paris. 1897. 

8 Therapeutique des Maladies Veneriennes, Paris, 1876. 

9 Lehrbuch der Syphilis, etc., Stuttgart, 1875. 

10 Lemons sur les Malad. V£n6r., Paris, 1883 and 1895. 


NEW-GROWTHS. 


639 


finger, covered by a handkerchief dipped in a weak spirit-and-water 
lotion, to which tincture of cinchona and of myrrh may be added in 
any desired proportion. Tobacco in every form is decidedly injurious. 
Often the patient should early be sent to a competent dentist for the 
extraction or the filling of carious teeth, and for the removal by the 
file or the dental engine of all sharp projecting edges. 

Malt liquors, wines, and spirits should be employed solely under 
the explicit direction of the physician. They are exceedingly useful 
in debilitated subjects of a certain class, and need not be prohibited 
in toto to those long habituated to their use. At the same time, an 
improper use of these stimulants, it perhaps need not be said, is in the 
highest degree harmful. When employed at all, they should rigidly 
be restricted to the dining-table and the hours of meals. 

A compliance with the laws of hygiene is even more requisite for 
the syphilitic than the non-infected. Fresh air, social amusements, 
exercise, the regular routine of business life, or, when this has proved 
exhausting, the recreation of travel—the claims of all these need at 
times to be urged by the physician. With this the patient should be 
encouraged to free his or her mind from needless anxiety, and to avoid 
particularly the company and conversation of those similarly infected, 
whose opinions are based too often upon ignorance, or upon a knowl¬ 
edge of half-truths. The literature of syphilis, for a similar reason, 
is to be eschewed, as the mass of patients, too many of whom purchase 
treatises on the subject, are able only to glean imperfectly the meaning 
of the authors consulted. 

It should be a rule to urge married patients frankly to inform the 
respective partner of the fact of infection, for the sake of both. 
When this advice is followed much future trouble is avoided, and one 
of the obstacles to a completely favorable issue is at once set aside. 
Many instances occur in which the disruption of the conjugal bond 
results from infection of one, but usually of both parties; it is a strik¬ 
ing argument, however, in favor of the policy here urged, that instances 
are very rare in which a frank and honorable confession has been fol¬ 
lowed by separation. It may be added that in no one of the c< con¬ 
fessed” cases has there been a subsequent infection of the innocent. 
The larger number of married patients are husbands. Recently infected 
young adults who have contracted a marriage-engagement should inva¬ 
riably claim release from such a tie for the sake of all concerned. 
The syphilitic nurse must at once be taken from the sound nursling, 
and the child with hereditary syphilis must be suckled only by its 
mother, who, according to Codes’s law, the exceptions to which are so 
few as to prove the rule, always enjoys immunity against the diseased 
mouth of her own child. 

Turning to the consideration of the medicaments employed in syph¬ 
ilis, it is to be remarked at the outset that there is no routine plan of 
treatment which in every case can advantageously be employed. In 
no respect do physicians so differ from each other, judged by the stand¬ 
ard of professional skill, as in their ability to use a single remedy with 
success. He who has the largest armamentarium is not always either 
the best equipped or the most successful. Mercury, iodin, iron, and 


640 


DISEASES OF THE SKIN. 


quinin are the great remedial agents in syphilis, but they may vainly 
be used by one man in the long effort to accomplish that which another 
speedily and brilliantly achieves by the use of the same remedies, 
employed with greater skill. 

Of the other substances vaunted as either advantageous or specific 
in the treatment of the disease, no one possesses any claim whatever 
to the confidence of physicians. Sarsaparilla, dulcamara, stillingia, 
guaiacum, tayuya, mezereon, and the long list of other vegetable prep¬ 
arations whose virtues have thus been extolled, are all as harmless in 
themselves as they are ineffectual for the relief of the malady. 

Before proceeding, however, to assume the responsibility of direct¬ 
ing a course of treatment for syphilis with remedies of acknowledged 
value, the physician will do well to remember that no two cases of the 
disease are precisely alike, and that there is the widest range between 
the most benignant forms encountered in private practice and the 
malignant cases that are seen in hospital-wards. Some forms of the 
malady are absolutely so mild as to constitute merely an inconvenience ; 
others are so severe as to destroy life. It is an axiom in venereal disease 
that more patients perish annually from blennorrliagia and its results 
than from syphilis. There could be no greater error than to treat any 
disease, exhibiting so wide a variation in severity, by a uniform method. 

Mercury, after the assaults upon it of generations of men of ad¬ 
mitted wisdom and candor, stands to-day unrivalled as a remedy for 
the relief particularly of those stages of syphilis in which the skin is 
involved. Administered with skill, it can be employed for years with 
immense advantage to the syphilitic patient, who, during a well-regu¬ 
lated mercurial course, should gain in weight, improve in vigor, and 
exhibit a healthy color of the skin. No competent physician of to-day 
employs it in such a manner as to induce salivation or other toxic 
consequences. Such effects of the remedy result from the carelessness 
or the ignorance of the prescriber. It should be remembered that in 
every discussion of the merits of mercury in syphilis, both physicians 
and patients have been guilty of the ignorance or the folly of ascribing 
to the remedy the disastrous effect of the disease. 

Mercury may be given by the mouth, by inunction, by subcutaneous 
injection, or externally by the aid of the vapor-bath. Decidedly the 
most popular method, and that productive of least inconvenience to 
all concerned, is the method by ingestion. 

Ingestion . In this treatment of syphilis the mild chlorid, bichlorid, 
and bicyanid of mercury, or blue mass, may effectively be employed. 
These preparations, however, are rather less adapted than others for 
continued employment during long periods of time, and are open to 
the objection of cither readily undergoing rearrangement into more 
stable compounds of the metal, or of producing undesirable irritative 
effects. With the protiodid and the biuiodid of mercury an impres¬ 
sion can be produced upon the system that can readily be proportioned 
to the exigencies arising in every case, which can be sustained during 
that “ chronic medication’’ which Fournier declares to be requisite in 
every chronic disease, and which can be exerted without fear of imme¬ 
diate or of remote deleterious consequences. 


NEW-GROWTHS. 


641 


Treatment of syphilis by the mercurial selected for use should, as a 
rule, be begun only at the moment of evolution of constitutional symp¬ 
toms. The initial sclerosis of the disease is, to a remarkable extent, 
amenable to the action of the metal, but in the large proportion of 
cases it will cicatrize, when in an ulcerative stage, without having 
recourse to general medication. Early mercurial medication may well 
be reserved for such primary lesions as are threatening in symptoms, 
and for such individuals as require or demand speedy cicatrization of 
their chancres, as, for example, those about to travel beyond the reach 
of medical assistance. Personal experience fully confirms the wisdom 
of the teaching which reserves specific medication until the second 
period of incubation has passed. No local or general treatment can 
avert either a mild or a severe explosion of symptoms after that period 
is completed. In experiments made to determine this question of 
delay there has been either the production of strikingly irritative 
effects, such as very marked relapse, or unusual increase in the volume 
of the initial sclerosis immediately before the evolution of the first 
syphilodermata, or a distinct obstinacy in the latter to the action of 
the medicament employed. 

In the early stages of syphilis in adults the protiodid of mercury 
may be named as one of the most trustworthy preparations. Of all 
classes of adult patients, including strong men and delicate women, 
there are scarcely 2 per cent, who cannot take it, if the dose be pro¬ 
portioned to individual susceptibility. It is usually administered in pill 
or in tablet form, in doses of (0.01), \ (0.013), \ (0.016), or -J- (0.022) 
of a grain, three times daily, combined with the extract of gentian. 
The dose may gradually be increased, according to the necessities of 
the case, from J (0.032) to 3 (0.207), and even 4 (0.266) grains in the 
twenty-four hours. Many of the gelatin-coated pellets found in the 
market contain accurately divided doses of the salt. The sugar-coated 
pills of Gamier and Lamoureux, containing each 1 centigramme of 
the protiodid, are efficent and largely employed. 

Beginning with a minimum dose, this remedy is to be steadily 
exhibited, and the daily quantity consumed to be very gradually 
increased, until the degree of tolerance of which the patient is capable 
has been ascertained. Should the stools become frequent, pain be 
excited, or a slight effect produced upon the mouth, as indicated by a 
metallic taste, moderate increase in the quantity of saliva, or any notice¬ 
able degree of tenderness of the gums, the dosage is to be gradually 
diminished until these symptoms disappear. Often the withdrawal of 
£ (0.013) or J (0.032) of a grain daily will suffice to enable the patient 
to tolerate the quantity thus diminished. The medication is to be 
faithfully continued until the object in view is obtained, viz., relief of 
all symptoms of the disease. 

Keyes’s well-known so-called “ tonic treatment of syphilis” is 
based largely upon the plan whose outline is merely sketched above. 
By the method which this author has certainly popularized the dosage 
is increased only on each third or fourth day, until irritative effects 
are produced, when, after an interval of two days, the quantity taken 
at the time of the production of such effects is reduced from one-half 


642 


DISEASES OF THE SKIN. 


to one-third. This reduced quantity is termed the “ tonic dose/* and 
is thereafter continued throughout the treatment in “ nearly all condi¬ 
tions of health or disease .’’ 1 

This method of treatment in many cases is admirably effective and 
is eminently safe. Still, viewing the subject with the conservatism 
which its importance justifies and which a mass of clinical facts de¬ 
mands, it may well be doubted whether it is always proper to admin¬ 
ister a mercurial for weeks at a time to a man in apparently good 
health. With the active measures at immediate control in the vapor- 
bath, it is usually safe and not unwise to suspend temporarily specific 
medication of the patient who exhibits such amelioration of symp¬ 
toms as to be free from external manifestations of the disease. 
Every syphilis has its periods of activity and repose. Such period 
of repose will well be employed in the administration of iron, which, 
as tending to relieve the distinct chloroanemia of the disease, has 
its claims to recognition in the list of u specific” remedies. No 
case of syphilis can be said to have properly been treated in 
which this remedy has not been given for at least a part of the time 
during which the patient was under observation. The citrate of 
iron and quinin is an excellent preparation administered at the meal- 
hours, in a small quantity of sound sherry wine; or the iodid of iron 
may be employed in syrup, or in the pills made by the formula of 
Blanchard, or in Vallet’s mass. In some cases the muriated tincture 
of iron may be employed, but the physician will always be careful 
about ordering an acid preparation of any kind during the interval of 
a mercurial course. There is no form of anemia which responds more 
promptly to the chalybeates than does that produced by the syphilitic 
virus. 

The biniodid of mercury may be substituted for the protiodid when, 
for any reason, it may be thought desirable, beginning with a mini¬ 
mum dose of ^4 grain ( 0 . 001 ), and increasing this gradually to 
(0.0016), or rarely to ^ (0.0033), either in pill or in solution. The 
average dose of -fo (0.0016) of a grain in pill-form, administered three 
times daily, soon after eating, is tolerated by the majority of all patients 
of both sexes without consciousness of unpleasant effects. 

For those who prefer to use the more active and correspondingly 
dangerous salts of the metal, calomel may be administered in 1 - or 
2-grain doses (0.066-0.133) three times daily, in combination with an 
opiate to prevent its action on the bowels, or, as recommended by 
Peters, in y^-grain dose (0.0066) every hour. Small doses of blue- 
mass or of gray powder may also be employed. According to the 
traditions of the profession, the gray powder is most suitable for 
children and infants, but since the frequent discovery in the drug of 
the corrosive chlorid, either as of early or of late chemical production, the 
gray powder is less esteemed. The decimal trituration of calomel with 
sugar-of-milk is a far more suitable compound. Corrosive sublimate, 
in doses of from ^ (0.0033) to y 1 ^ (0.005) of a grain, is exhibited 

1 Consult the interesting paper of the author in the American Journal of the Medical Sciences, 
January, 1876 ; also his later exposition of his views in the Philadelphia Medical Times, Novem¬ 
ber 25,1882, p. 337. 


NEW-GROWTHS. 


643 


in pill-form or in solution, and is probably more generally employed 
in the treatment of syphilis than any other mercurial salt. The objec¬ 
tions to its use are suggested above. Though constantly employed in 
the public charities, where it is furnished as a cheap and a convenient 
substitute for the more elegant preparations in the market, it is much 
less frequently ordered for syphilitic patients in private practice. 
When given in solution it produces a disagreeable metallic taste in 
the mouth that some patients can perceive after the lapse of six hours. 

With many physicians of wide experience it is customary to employ 
opium, either alone or in connection with the use of mercury, for the 
relief of ulcerative or other lesions of syphilis. Sometimes it is 
employed for the purpose of relieving pain, sometimes to prevent 
the cathartic action of the metal upon the bowels, and again because 
it is supposed to possess some power of arrest over the destructive 
action of the disease. It should not, as a rule, be exhibited when 
by reducing the mercurial or exchanging the latter for a ferruginous 
dose the same result can be reached. Few syphilitic patients 
are in the end brought to the desired termination of the disorder 
by the use of a remedy which interferes with assimilation and 
digestion; such a remedy is opium in all its forms. Temporary advan¬ 
tage is often gained by its employment, but this may be more than 
counteracted by its ultimate effect upon the gastro-intestinal tract. 

Inunction. Mercury is also satisfactorily introduced by the method 
of inunction. The metal, when thus employed, is readily absorbed 
by the system, and its therapeutic value is no less evident. Inunction 
should be employed in every case which admits of it, since the gastro¬ 
intestinal tract is thus left undisturbed, and, further, the dose of any 
needed chalybeate or of the iodid of potassium per os, can be regulated 
without increasing or diminishing the quantity of mercury in daily use. 
Mercurial ointment is commonly used for this purpose, but a much 
more cleanly substitute for it is provided in the oleate of mercury in 
the strength of 10, 15, or 20 per cent. The oleate is somewhat more 
readily absorbed from the surface of the skin. The 10 per cent, oleate is 
in general to be preferred to the stronger preparation, as less liable to 
irritate the surface of the skin. From J drachm to 1 drachm (2.-4.) of 
either the ointment or the oleate may be rubbed into the skin at night 
before retiring, and the part selected for inunction be cleansed by wash¬ 
ing in the morning. Both preparations, if continually applied to a single 
portion of the skin, are liable to produce a mild local dermatitis or an 
eczema, hence it is wise to select on successive evenings a fresh portion 
of integument for the local application, preferably that where the epider¬ 
mis is relatively thin, as, for example, the flexor aspects of the joints. 
The patient can thus upon one evening anoint the inner faces of the 
thighs; upon the next, the sides of the chest; upon another, the loins, 
etc., taking care to avoid surfaces where an induced eczema is likely to 
prove especially annoying, such as the scrotum, the axillae, and the 
groins. The ointment in some cases may be well rubbed into the soles 
of the feet previously soaked in warm water, after which the socks or 
stockings may be drawn over the feet for the night. In the case of 
infants the inunction is well performed by the natural movements of 


644 


DISEASES OF THE SKIN. 


the child, if a flannel swathing-band previously smeared with the salve 
be wrapped about its belly, so that the mercurial preparation is kept in 
contact with the skin. Should local irritative effects be produced, these 
subside rapidly, as a rule, after a warm alkaline ablution followed with 
a bland dusting-powder. Subsequently or even before such accident 
in the case of infants or of patients having unusually sensitive skins, 
the mercurial salve may be mixed with equal parts of lanolin, lard, 
or olive oil. As some patients become disgusted with this routine, it 
is well at the onset to flavor the substance selected for inunction with 
lavender, rosemary, or bergamot. 

In America too little attention has been attracted to the treatment 
of syphilis by mercurial inunction. With this fact in view the preced¬ 
ing paragraphs, which describe the use of mercury by the mouth, are 
to be understood as related in all cases to the employment of the metal 
by the skin. It is well to order inunction in all practicable cases; to 
save the stomach as much as possible; to continue with the mercurial 
ointment nightly, weekly, or less frequently, so long as there is danger 
of relapse; and to adjust carefully the quantity employed to the exigen¬ 
cies of the case. In this manner patients may be relieved of all 
symptoms of the disease who have not during their treatment swal¬ 
lowed a dose of mercury, and the permanency of whose relief may be 
tested during years of subsequent observation. 

Fumigation. One of the most effective methods of administering 
the metal is by fumigation in the mercurial vapor-bath. It is employed 
by many experts as the sole means of exhibiting the mercurial selected 
for use, but it is, for the average of patients, too inconvenient for con¬ 
tinuous employment. It should regularly be ordered, first, in all cases 
where the earliest syphilodermata are intense, generalized, and partic¬ 
ularly conspicuous upon the face; second, in all obstinate cases where 
the patients are not women nor cachectic subjects of either sex; third, 
at the outset of treatment of many “ ignored” cases, where the syph¬ 
ilodermata, either more or less generalized, have proceeded to uninter¬ 
rupted evolution; fourth, in the severe cases of patients coming from 
the country to the city, who are able to remain but a brief time within 
reach of advantages offered in the metropolitan centres. From J to 
1 drachm (2.-4.) of calomel, metallic mercury, the bisulphuret, the 
black oxid, or hydrargyrum cum creta may be employed for each 
bath. It is common to order 1 scruple to 1 drachm (1.-4.) each of 
calomel and cinnabar. The patient is stripped of his clothing and 
seated in a chair, the patient and chair being completely enveloped in 
blankets, which are closely fastened at the neck of the bather. Beneath 
the chair is an alcohol lamp, surmounted by a tin vessel containing 
water in ebullition, the hot vapor of which in a few moments induces 
copious perspiration. When this result is obtained the lamp is brought 
beneath a metal plate containing the substance to be volatilized. The 
patient remains exposed to the vapor about ten minutes after this pro¬ 
cess of sublimation is finished, and retires at once to bed without 
cleansing the skin, the fumigation preferably being conducted before 
the hours of sleep. In the morning a bath may be taken for the pur¬ 
pose of cleanliness. It is more convenient in the generation of the 


NEW-GROWTHS. 


645 


vapor in this way to make use of Mr. Henry Lee’s safety fumigating- 
lamp, but the materials requisite for the production of all desired effects, 
with the exception of the alcohol lamp and the drug, can be procured 
of auy good tinsmith. In the city, male patients are often sent to 
bath-houses, where the fumigation is conducted in the daytime; and, 
as a consequence, they rarely experience unpleasant effects, such as are 
popularly associated with u taking cold” after exposure to the action 
of the mercury. In most of these establishments provision is so made 
that the head also can be exposed to the mercurial fumes, respiration 
being conducted through a tube in connection with pure air, a provision 
useful in certain cases of emergency; and only “ emergency cases ” 
should be required to resort to fumigation of the head. 


Fig. 79. 



Lee’s safety-lamp for fumigation. 


The happy effect of the mercurial vapor-bath is often marvellously 
rapid. A generalized syphiloderm may become well-nigh indistin¬ 
guishable upon the surface after four baths at intervals of two days 
each. With this potent agency at hand, it can well be understood 
how the skilled physician can afford to watch from week to week his 
syphilitic patient taking a dose of iron internally and employing inunc¬ 
tion externally, the few lesions fading slowly from the surface, all fears 
quieted, and the nutrition sustained at a high grade. In comparison 
with this combined method, the swallowing of blue mass, or of calomel 
and opium, should be regarded as a more clumsy and dangerous pro¬ 
cedure. 

Subcutaneous Injection. The injection of mercury into the deep 
muscular tissue (the gluteus in its thickest part with the muscle wholly 










646 


DISEASES OF THE SKIN. 


relaxed; the trapezius above the upper scapular angle with equal lack 
of tension), as well as when practised more strictly hypodermatically, 
requires all antiseptic precautions both as to the point where the needle 
is inserted and as to the instrument itself. It is to be remembered 
that these injections have occasionally proved fatal (calomel, gray oil), 
and grave mischief has followed in one or two instances from visceral 
troubles. 

This method, which was first popularized by Lewin, 1 is open to the 
serious objection of requiring the aid of a physician for the admin¬ 
istration of each dose. It is efficient and speedy, but will probably 
always find largest favor in the treatment of hospital patients, who are 
there completely subject to the orders of their medical attendant. At 
the site of the injections, too, not rarely abscesses have formed. Cor¬ 
rosive sublimate, (0.005) or J grain (0.008), dissolved in 10 or 15 
minims of distilled water, may be injected at a time, the operation 
being repeated upon about twenty occasions. Bamberger, of Vienna, 
reported favorable results after the injection of an albuminate or a 
peptone of mercury, thus attempting to avoid the danger of localized 
abscesses, and insuring speedy absorption of the metal. All formulae, 
however, proposed for preparation of solutions of this character have 
hitherto proved imperfect, both in consequence of failure to obtain a 
pure metallic albuminate, and also from lailure of permanency iu the 
solution. Staub’s formula, the result of experiments made by Hepp, 2 
may be taken as a sample of the rest: 


K.—Hydrarg. chlorid. corros., gr. xviij ; 1|25 

Ammon, chlorid., gr. xviij ; 125 

Sod. chlorid., Z ]; 4 

Aq. dest., f^iv; 128j M. 

Dissolve, filter, and add the white of one egg in distilled water sufficient to 

make ,^iv (128.); fifteen minims of the solution contain about one-twelfth 

of a grain (0.005) of the sublimate. 


The treatment of syphilis by mercurial injection has largely been 
extended since its first acceptance as a scientific procedure. It should 
never be ordered save in cases specially indicating its employment. With 
some of the other methods employed, injection provides for the exclusion 
of the medicament from the gastro-intestinal tract, and accomplishes 
the desired effect with a minimum and exactly mensurable dosage. 
The objections to its systematic employment outside of hospitals are 
chiefly the need of a physician or an expert to administer the dose. 

The articles employed for hypodermatic injection are well summar¬ 
ized by Taylor as follows : 

Insoluble salts of mercury. Here are included calomel in an aver¬ 
age dose of 1 grain (0.66) suspended in vaselin oil, salt and water, 
or mucilage and water; metallic mercury, from 6 to 30 grains (0.40-2.); 
oleum cinereum, gray oil, mercury with liquid vaselin or lanolin, 20 to 
50 per cent., 0.05 to 0.1 at each injection; and the yellow and the 


1 Die Behandlung der Syphilis mit Subcutaner Sublimat-injection, Berlin, 1869 ; also translated 
by Proegler and Gale. Phila., 1872. 

2 Traitement de la Syph. par les Inject. Hypoderm. de SublimS. These de Paris, 1872. 


NEW-GROWTHS. 


H47 


black oxids of mercury, corrosive sublimate, cyanid of mercury, and 
combinations of these with the iodid of potassium and other salts. 

The so-called u antiseptic group ” includes the salicylate of mercury. 
A Pravaz syringeful is injected every third day in the gluteal region 
beneath the muscular fasciae, of the following: 

H.—Hydrarg. salicylat., gr. xv-xxiv; 1060-1.6 

Mucil. acac , gr viij; |533 

Aq. dest, f^vss; 1751 M. 

In this group are also included carbolate or phenate of mercury; 
thymolate (10 per cent, suspensions in fluid paraffin); and the benzoate 
associated with chlorid of sodium, two parts, and muriate of coca'in, 
one part, in five hundred of water. 

The amide group includes formamide of mercury, 1 per cent, solu¬ 
tions; glycocoll of mercury, alaninate of mercury, and succinimid of 
mercury, the last two in 1 per cent, solutions. 

Beside these mercurial preparations, iodid of potassium and iodoform 
have subcutaneously been injected in a few instances, it is claimed, 
with advantage. 

Ptyalism, stomatitis, fetor of the breath, or a fungous condition of 
the gums with inappetence and other characteristic symptoms of the 
ill-effects of mercury, including all grades of gastro-intestinal disturb¬ 
ance, are rarely seen in modern practice, and they should never be per¬ 
mitted to occur in a properly regulated mercurial course. When they 
are produced, the tongue projected from the mouth is usually tumid, 
and exhibits at its lateral borders the imprints of the inner faces of the 
molar teeth. Its surface is also covered in various degrees with a thin, 
dirty-grayish coat; and the odor of the breath is peculiarly offensive, 
being often noticeable at a distance of several feet from the patient. 
In such cases the food should be liquid and nutritious, both hot and 
cold drinks should scrupulously be avoided, and the mouth frequently 
be cleansed with washes containing dilute liquor sodae chlorinate, or 
the chlorate of potassium, or a very weak solution of carbolic acid. 
Internally, the citrate of iron and quinin may often be used with advan¬ 
tage, and, in particularly severe cases, the chlorate of potassium to 
the extent of 1 drachm (4.) daily. The compressed tablets of this 
salt, each containing 5 grains (0.33), are available for this purpose, 
being slowly dissolved in the mouth, the medicated saliva and mucus 
being then well diffused over the inflamed buccal membrane, tongue, 
and fauces. The mercurial is to be suspended in all cases, and iced 
water is to be interdicted, gangrene having followed its use in a few 
cases. In milder forms tincture of myrrh and of cinchonin, diluted 
with sweetened water, or honey and water, will be sufficient for local 
medication of the mouth. 

Iodin is chiefly employed in syphilis in the form of the iodid of 
potassium. It possesses some value, without question, in every stage 
of syphilis, and is, therefore, indiscriminately used by many practi¬ 
tioners. Its value, however, in so-called “ late secondary” and 
u tertiary stages ” is incontestably greater than in the earlier lesions 
of the disease, and its use should largely be restricted to the particular 
periods in which these manifestations appear. Every prudent physi- 


648 


DISEASES OF THE SKIN. 


cian will hesitate before ordering for a disease exhibiting cutaneous 
lesions a remedy which will positively produce such lesions in the 
majority of all patients ingesting it. In this connection the reader 
will do well to consult the chapter on Dermatitis Medicamentosa, in 
which the various eruptions produced by this drug are recorded. 
Thoughtful men are beginning to inquire, in the light of the present 
knowledge upon this subject, to what extent the syphilodermata have 
in the past been aggravated or obscured by this remedy. He would 
indeed be bold who should attempt to prove that the medicamentous 
eruptions thus excited have not, in the past, figured largely in the 
catalogue of the syphilodermata. 

The value of the iodin compounds, nevertheless, properly adjusted 
to the age and other conditions of the disease, is incontestable. 
Whether given alone, or by the so-called u mixed ” treatment in com¬ 
bination with mercury, or administered internally while a mercurial 
is introduced by the skin, or exhibited by alternation with the metal, 
in each these compounds find a special value, and may simply be in¬ 
dispensable. The iodid of potassium may be given in doses of from 
5 grains (0.33) to 1 drachm (4.), well diluted with water, three or four 
times daily after eating. The larger doses should invariably be 
reached gradually; they should never be employed except by special 
order of the physician, and when the patient is within easy reach of 
the latter; and they should always be ordered with the understanding 
that the patient shall diminish or suspend treatment in case of unpleas¬ 
ant results. Symptoms of iodism, other than the production of cuta¬ 
neous lesions, such as coryza, oedema of the eyelids, and faucial 
irritation, are apt to be the result of the first few doses of iodin 
ingested, and these symptoms often bear no relation to the size of the 
dose. In certain cases, 1 or 2 grains (0.066-0.133) will be sufficient 
to produce the most disagreeable toxic effects, which, if they occur 
before the remedy be suspended, may not return with even the largest 
doses. In a few cases, the iodid of potassium produces violent toxic 
effects in any dose, owing to exceptional idiosyncrasy. Both the 
chlorid of ammonium and carbonate of ammonium are recommended 
for use in combination with the iodid of potassium, as increasing its 
efficiency. The iodids of sodium, ammonium, and lithium possess 
also, without question, some influence over the disease, but they are for 
most cases less efficacious than the potassium salt. Of the three iodids 
named, the iodid of lithium is apparently most prompt in its effects. 

There is no combination of mercury with the iodid of potassium 
that is employed more frequently than the well-known u sirop de 
Gibert,” which though first popularized in the Saint Louis Hospital, 
in Paris, has since extensively been employed in the United States. 
It has slightly been modified to suit the varying tastes of many sur¬ 
geons. It is ordered in the folowing formula : 


K •—Hydrargyri biniodid., gr. ss-ij ; 

Potass, iodid., ^ij—viij ; 

Gentian, syrup, (vel 1 
syrup glycyrrhiz.), j- aaf^ij; 

Aq. dest. , J 

Dose —A teaspoonful in water after eating. 


1033-0.13. 

8-32! 

64 

M. 


NEW-GROWTHS. 


649 


The syrup of licorice disguises the taste of the drug better than most 
of the other syrups used. With the dosage carefully regulated, a few 
drops (1 to 15) may be administered with advantage to children. 

The following are indications for the use of the iodid of potassium 
either aloue or by the so-called “ mixed ” method in the treatment of 
syphilodermata: the occurrence (1) of “ late/ 7 tubercular gummatous, 
or ulcerative lesions; (2) of formidable nervous, visceral, or other non- 
cutaneous symptoms with early or late, mild or severe syphiloder¬ 
mata, as, for example, grave ulcerations of the velum or the fauces with 
a symmetrical macular eruption, or coincidence of a generalized pus¬ 
tular or a papular syphiloderm with hemiplegic, aphasic, ocular, or 
renal complications; (3) of early or late manifestations which either 
assume the so-called “ galloping” type, being rapidly succeeded by 
more and more formidable symptoms, or which exhibit the capricious¬ 
ness of the disease in a reversal of the usual sequence of evolution, as, 
for example, when symptoms commonly counted as ‘‘late” phenomena 
occur within a few weeks after infection and are followed by the early 
symmetrical rashes; (4) of early or late symptoms occurring in cachec¬ 
tic, strumous, or otherwise debilitated patients. Mercury is assuredly 
not a tonic in tuberculosis commingled with syphilis. 

The local treatment of the initial sclerosis of syphilis by complete 
excision, lauded by Auspitz, has been practised (since the date of his 
paper in 1879) by Kolliker, Zeissl, Leloir, Chadzynski, Mauriac, 
and others. 1 The result has proved conclusively that such operative 
interference furnishes no bar to constitutional infection. Simultaneous 
extirpation of all lymphatic glands iu the vicinity of an initial scle¬ 
rosis, with ablation of the latter and a mass of tissue about it, have 
repeatedly proved unavailing to prevent the occurrence of systemic 
infection. Chancres should not be destroyed by caustic agents of any 
character, as the caustics are liable to induce either irritative or inflam¬ 
matory effects which may be followed by denser induration. Oint¬ 
ments, as a rule, are also objectionable, exception being made in the 
case of hemorrhagic lesions when the removal of an adherent dressing 
is followed by unpleasant consequences. Cleanliness with soap and 
water is of chief importance. After each local bath the parts may be 
dusted with a dry powder, such as iodoform, iodol, boric acid, zinc 
stearate, calomel, zinc oxid, hydronaphtol, or starch, or be dressed 
with a piece of soft lint, saturated in lotio nigra, or, even better, a 
spirit-lotion containing tannin and carbolic or boric acid. Opiated 
washes may be requisite in all painful and ulcerative lesions. When 
a phagedenic tendency is shown deep cauterization may be required, and 
the subsequent local employment of solutions of potassic permangan¬ 
ate, from 2 to 10 grains (0.133-0.666) to the ounce (32.) of water. 

When a primarv venereal sore of any character (the initial sclerosis 
of syphilis or the 'chancroid) actually falls into gangrene or becomes 
phagedenic, or, even in the absence of both of these calamities, extends 
rapidly in depth or superficial area, cauterization should no longer be 
tried. ' The most effectual treatment of these complications in the 


i See Keyes’s later communication on this subject, loc. cit. 


650 


DISEASES OF THE SKIN. 


genital region is by the employment of the continuous hot-water bath> 
aided by antisepsis. The patient remains seated in the bath (the water 
being of the temperature most grateful to the affected surface and with 
great care maintained at that degree of heat) throughout the day, or, 
in formidable emergencies, if carefully watched, by day and night. 
The bath is left by the patient only for the purpose of evacuating the 
bladder or the rectum. Granulation and repair speedily set in. When¬ 
ever the patient leaves the water the parts are well dusted with iodo¬ 
form or with iodol. By this invaluable means, in both hospital and 
private practice, cicatrization may be secured of extensive ulcers which 
reach over the penis half-way to the pubic region. 

Local treatment of the syphilodermata may be demanded either by 
reason of their appearance on exposed surfaces, as the face and the 
hands, or by reason of their obstinacy or threatening character, as 
when they are rapidly ulcerating. Macular and papular lesions of 
the face may be treated by local applications of mercury: 5 per cent, 
oleate; mercurial ointment, 1 to 2 drachms (4.-8.) to the ounce (32.) 
of cold cream or of vaselinpred oxid, from 2 to 4 grains (0.133- 
0.266) to the ounce (32.); or ammonio-chlorid, J to 1 scruple (0.666— 
1.33) to the ounce (32.) of ointment. Lotions of bichlorid, 1 to 2 grains 
(0.066-0.133) to the ounce (32.) of cologne, are also efficient. These 
preparations will each be found much more valuable if used at night 
before retiring, and left upou the face during the hours of sleep, and 
each is well preceded by hot bathing of the face for several minutes, 
as in the preparatory treatment of the same region in acne papulosa. 
Indeed, the sulphur preparations employed for the relief of that disease 
will at times be found useful also in the local treatment of the syphilo¬ 
dermata. 

Hot ablution is particularly useful in the treatment of the scaling and 
frequently fissured lesions of the palms and soles, the pain of which 
local symptoms in severe cases is greatly alleviated by this treatment. 
After the epidermis in these parts has been well macerated, the hands 
or the feet should thoroughly be dried, and the mercurial, tarry, or 
other salve be well rubbed in. The glove or the stocking should then 
be drawn over the part. 

Secreting eondylomata, flat papules, vegetations, etc., also require 
bathing in soap and water, especially when situated at the mucous 
outlets of the body or on the scalp. When the secretion is offensive 
in odor, boric or carbolic acid, thymol, or chlorinated soda should be 
added to the lotion. Cleanliness, indeed, is more essential to the syph¬ 
ilitic patient, man or woman, than to the healthy. After the cleansing 
or disinfecting ablution the parts should be dressed with a powder, 
such as dry calomel, iodoform, iodol, hydronaplitol, bismuth, zinc 
oxid, salicylate of soda, or starch. Vegetating lesions of these regions 
may require also pencilling wfith a crayon of nitrate of silver. Oint¬ 
ments, as containing grease, are decidedly objectionable local applica¬ 
tions. 

Crusted and ulcerative lesions, large or small, are to be treated in 
accordance with general principles. Crusts should always be removed 
either by the oil and soap-and-water treatment, or by the dermal 


NE W- GROW THS. 


651 


curette, after which removal the underlying ulcers should thoroughly 
be cleansed, pencilled with nitrate of silver, filled with powdered boric 
acid, iodoform, iodol, or calomel, or touched with a 5 to 20 per cent, 
solution of carbolic acid, and then be dressed with a dilute oint¬ 
ment of nitrate of mercury, 1 to 2 drachms (4.-8.) to the ounce (32.). 
Large syphilitic ulcers are often encountered on the surface of the 
lower extremities, and in this situation elastic compression by the rub¬ 
ber bandage will greatly accelerate their cicatrization. 

The syphilodermata are in general particularly amenable to the 
action of the mercurial vapor-bath, which may be regarded as exert¬ 
ing upon them both a local and a constitutional influence. Those 
existing upon the face are thus benefited by exposure to the metallic 
vapor in the “headpiece” arrangement already described. The 
patient may less comfortably also avail himself of the same local 
treatment by holding the breath and exposing the head and face for 
a few minutes at a time to the fumes of the mercury beneath the 
blanket, in the plan described as practicable at the bedside. 

It is within reasonable bounds to say that the syphilodermata, if 
treated locally by the measures described as useful in non-syphilitic 
cutaneous affections of similar type, will always proceed to a satisfac¬ 
tory involution, if the general treatment be skilfully ordered. 

Prognosis. The prognosis of syphilis may be said to be in general 
favorable, the popular opinion on the subject being at variance with 
fact. Benignant syphilis may even disappear without treatment. 

Malignant forms of the disease may, but rarely do, destroy life. 
The element of treatment, both as to its character and the period of its 
continuance, enters more largely into the estimate upon which a prog¬ 
nosis rests than it does in most other disorders exhibiting cutaneous 
symptoms. Syphilis untreated, whether because of a failure to recog¬ 
nize its real character, or of ignorance, poverty, neglect, or dissi¬ 
pation, is usually grave. The same may be said of syphilis occurring 
in strumous, tuberculous, and cachectic subjects, and those enfeebled 
by age, by other diseases, by chronic alcoholism, oi? by sexual excesses. 
Hereditary syphilis is by far the gravest form, not merely because of 
the tender age of its victims, but also because they, at the earliest 
period of their lives, are burdened by a disease which may first attack 
organs essential to life. 

The majority of adult American patients sooner or later get rid of 
all active manifestations of the acquired disease, marry, and beget in 
the eud sound children. 


Chancroid, 

This term has very generally been adopted in America for the pur¬ 
pose of designating the virulent, local, contagious ulcer of the geuitals, 
designated also as the “ simple,” the “ soft,” or the “ non-infecting” 
chancre, the chancrelle of French authors. Chancroid has no relation 
to syphilis, nor to the neoplasmata with which syphilis is commonly 
classified. As it is, however, a disease with which the initial sclerosis 
of syphilis may be confounded, and is, also, not merely a venereal 


652 


DISEASES OF THE SKIN. 


lesion, but one which may be encountered upon the skin as well as 
upon mucous surfaces, it is briefly described in this connection. 

Chancroids present as distinct a uniformity of feature as the lesions 
of vaccinia or of herpes zoster. They are thus stamped with special 
and readily recognized characteristics, differing in this respect from 
the various modes in which the first lesion of syphilis may declare its 
nature. The virus, for such it must be termed, of the disease, is one 
sui generis , and derived exclusively from lesions of like character. This 
virus, which is contained in a purulent secretion, is capable of trans¬ 
mission by inoculation and auto-inoculation. After such successful 
inoculation there is no period of incubation. The results of experi¬ 
mental generation of the virus in human subjects indicate that the 
pathological process which it awakens can be determined within twenty- 
four hours after its introduction within the skin. At times, after acci¬ 
dental infection, eight and ten days elapse before the lesion of the 
disease is manifested, cases presumably in which the virulent secretion 
has remained pocketed in the orifice of a follicle or in a fold of mucous 
membrane, where its irritant effects have finally opened an avenue for 
its deeper ingress. When typically developed the chancroid is seen 
to be a pustular lesion, frequently multiple, of roundish outline, begin¬ 
ning as a pin-head-sized, turbid, vesico-pustule, rapidly enlarging to 
a pea- or bean-sized, well-developed, projecting, yellowish, globoid 
elevation of the epidermis, filled with greenish-yellow pus. When 
located in furrows or depressions of the surface it may have a linear, 
oval, or even a dumb-bell shape, the latter in consequence of extension 
from a sulcus to overlying folds. Clinically, the roof-wall of this pus¬ 
tule is not frequently encountered, the objective symptoms being the 
ulcers which represent the floors of separate lesions. These ulcers 
vary with the shape of the superimposed pustules, being round, ovular, 
or linear, occasionally irregular in outline, with sharply defined or cut 
edges; they have an uneven, pus-bathed floor; a faint pinkish areola; 
a supple, non-indurated base; an abundant puriform secretion; and 
are accompanied or* unaccompanied by pain, according to the degree 
of inflammation present. In consequence of the auto-iuoculability of 
the discharge these ulcers frequently give rise to others in the vicinity, 
as when the prepuce lies in contact with chancroids of the glans. 

The ulcers thus presented usually attain an average size of that of 
a pea or of a bean in the course of from ten to fourteen days; they 
then remain in an indolent and suppurative condition, showing no ten¬ 
dency to heal for a fortnight or three weeks; and finally they granulate, 
exhibiting the ordinary phases of repair. The resulting cicatrix is 
either transitory or, more often, indelible. In exceptional cases the 
ulcer spreads widely. In the groin it may attain a diameter of several 
inches; its floor secreting scantily; its edges, lurid, undermined, pur¬ 
plish, or ragged; its color reddish, bluish, purplish, or leaden. Fis- 
stulous tracts and sinuses, filled with an ichorus sero-pus, radiate in 
dependent situations; the base of the sore is densely indurated; its 
career may be prolonged for years, and induce finally a systemic 
cachexia not different from that seen in all chronic ulcerations of 
severe grade. In other cases the occurrence of gangrene, or phage- 


NEW GROWTHS. 


653 


dena, changes the features of the lesion to those of other ulcers under¬ 
going similar metamorphosis. 

Chancroids may occur upon any exposed mucous surface of the geni¬ 
talia of both sexes, upon the integument of the penis, scrotum, labia, 
thighs, fingers, perineum, perianal region, and, very rarely indeed, upon 
the face. In consequence of their tendency to relapse, their abundant 
contagious secretion, and their auto-inoculability, chancroids are more 
frequently encountered than is the primary syphilitic lesion, among 
the filthy, the poor, and the classes that frequent hospitals and dispen¬ 
saries. Among the wealthy, the well-to-do, and the cleanly this order 
of frequency is reversed. 

The chancroid ulcer is also much more frequently complicated by 
surgical accidents than is the infecting lesion of syphilis. This result 
is partly due to the prevalence of an ulcerative type in all its manifes¬ 
tations, and in part to its situation. Thus, the ulcer is often accom¬ 
panied by severe inflammatory symptoms, which may be aggravated 
both by phimosis and paraphimosis, occurring with stenosis of the 
preputial aperture, or with a long, lax, and redundant foreskin. Pha¬ 
gedena is also a formidable complication, whether of sloughing or of 
serpiginous tendency, the lesion in each case losing its chancrous char¬ 
acteristics. It is evident also that the disease may coexist with others 
of a different character. Thus, a single point may simultaneously be 
inoculated with chancroidal and syphilitic virus; the former, without 
an incubative period, followed rapidly by a pustular or an ulcerative 
lesion; the latter, after its incubation is complete, producing the char¬ 
acteristic symptoms of an initial sclerosis. Chancroids may also be 
found coexisting with secondary and tertiary syphilitic lesions of the 
genitals, with vegetations, with blennorrhagic discharges and balanitis, 
with pediculi of the pubes, and with herpes progenitalis. Patients of 
the class exhibiting these lesions not infrequently present themselves 
at public dispensaries with three or more of these concurrent disorders. 

One of the most serious complications of the chancroid is its associ¬ 
ation with a specific lymphangitis, periadenitis, or adenopathy. In 
this case the lymphatic trunks connected with the lesion become 
inflamed, indurated, and irregularly corded, with the overlying integ¬ 
ument often oedematous, reddened, and painful. The chancrous process 
in these vessels rarely terminates by suppuration. The bubo of chan¬ 
croid is more common, and this adenopathy may be either sympathetic, 
resulting from the severity of the process at the site of the lesion, or 
be virulent, due to the transmission of an inoculable pus to one or 
more of the glands in near connection with the source of the trouble. 
These different gland-complications may coexist in one person, in men 
more often than in women, and in about one of each four or five cases 
presented to observation. When inoculable pus has been formed in a 
neighboring gland, the latter is at once converted into the seat of an 
abscess, the pus of which, whether evacuated spontaneously or by the 
knife of the surgeon, speedily inoculates the lips of the wound through 
which exit has been obtained. The wound and contiguous abscess-cavity 
then form a large chancroidal ulcer, usually inguinal in situation, as 
the glands in this locality are nearest the most frequent seat of the 


654 


DISEASES OF THE SKIN. 


lesion. Such an inguinal ulcer discharges a greenish-yellow pus often 
commingled with blood; its borders are undermined, thin, livid, or 
purplish, and ragged; its floor is irregular, sloughy, and often covered 
by nodules representing the debris of glandular structure; from it 
depart sinuses traversing the tissues in the vicinity, often downward 
to the thigh, occasionally upward over the belly. When occurring in 
strumous and cachectic subjects, or when long neglected or misman¬ 
aged, the resulting disorder is one of the most serious character, and 
it may surpass in duration and severity certain of the varieties of lupus 
and epithelioma. 

These facts have an important bearing. It is true that syphilis is 
a constitutional disease, and that it usually occurs but once in a life¬ 
time. It is equally true that the chaucroid is evidence of a local 
and non-systemic disorder, producing only such constitutional effects 
as may all other local affections of chronic course and severe grade; 
but it is a blunder to suppose for these reasons that the chancroid 
is the milder of the two maladies. Many of its consequences are 
much more severe, and some of them even more malignant, than the 
average of syphilitic sequels, and even, as indicated above, are worse 
than some forms of other diseases usually counted as malignant. 
Greater attention should be generally directed to the truth respecting 
the comparative gravity of the two diseases, as there is widespread 
ignorance of the real facts. 

Diagnosis. Chancroid is to be distinguished from syphilitic chancre, 
but no skill, however great, and no experience, however wide, will 
enable the diagnostician, even when typical chancroid is present, to 
assert that syphilis will not follow, until the longest incubative period 
of the initial sclerosis of the last-named disease has elapsed without 
production of suspicious symptoms. The rule which necessarily fol¬ 
lows is imperative, and, being too frequently ignored, a great deal of 
bitter disappointment on the part of the infected individual, and of 
keen mortification on the part of the physician, has naturally resulted. 
No PATIENT SUFFERING FROM A CHANCROID CAN SAFELY BE PROM¬ 
ISED IMMUNITY AGAINST SYPHILIS UNTIL TWO AND A HALF MONTHS 
HAVE ELAPSED AFTER THE DATE OF LAST EXPOSURE. Subject to 
this essential reserve, the diagnosis rests upon the pustular, ulcerative, 
and discharging features of the chancroid, its failure to indurate at the 
base, its auto-inoculability, its appearance without previous incubation, 
its more formidable localized expression of disease, and the character¬ 
istics of the accompanying adenopathy. The short-lived, superficial 
vesicles of herpes progenitalis, often accompanied by tingling and pain¬ 
ful sensations, with sequels in the form of equally superficial, epider¬ 
mal excoriations, are not to be confounded with chancroids; yet it must 
be remembered that these lesions may also precede or may accompany 
any form of venereal disorder. Chancroids are to be distinguished 
also from secondary and tertiary lesions of the genitals, and from non¬ 
syphilitic vegetations and molluscum epitheliale of the same region. 

The 'pathology of the chancroid, though illustrated by the researches 
of Biesiadecki, Auspitz, and Unna, is yet not understood to an extent 
that will explain its specific character. The micro-organisms discov- 


NEW-GROWTHS. 


655 


ered in all coccogenous lesions are usually abundant and readily demon¬ 
strable. Those recognized by Ducrey, of Naples, 1 are short, thick 
bacilli measuring 1.46x0.50 micromillimetre. These observations 
were confirmed by Krefting, of Christiania; 2 while the bacilli dis¬ 
covered and claimed as pathogenic by Unna (his observations being 
later confirmed by Quinquaud and Nicolle) occur in the form of 
twisted coils and chains, measuring 1.25x0.33 micromillimetre. The 
etiological value of these observations remains to be determined. 

Anatomically, there is disclosed by the microscope a uniform, dense 
infiltration of the corium with elements which undoubtedly represent 
inflammatory metamorphosis of the connective tissue of the derma; 
degenerative changes where the ulceration has proceeded superficially; 
enlargement of vessels from thickening of their walls, often with 
diminished lumen; and relatively intact rete and corium at the lateral 
borders of the ulcer. This fully confirms the inferences suggested by 
a clinical study of the disease. Many roundish, circumscribed, clean- 
cut ulcers with purulent floors occur upon the skin, that bear no rela¬ 
tion to the chancroid disease. It is the history and career of the 
disease that stamp it with an individuality of its own. It is not the 
form and appearance of its pus-elements, but their power and potency, 
which make them singular. 

Treatment. The routine treatment of chancroids is by destructive 
cauterization with either nitric or sulphuric acid. Keyes recommends 
a previous application of pure carbolic acid, in order to benumb the 
part and thus render the subsequent application less painful. If em¬ 
ployed at all, the carbolic acid should carefully be wiped from the sore 
before the subsequent cauterization, as the two acids will explode if 
suddenly united. As the slough separates the ulcer may be dressed 
in accordance with the general principles governing the treatment of 
simple granulating wounds. Vinous, carbolated, and opiated lotions, 
powders of boric acid, iodoform, iodol, calomel, bismuth, and starch, 
simple unguents, and the interposition of a pledget of borated cotton 
between all affected and sound tissues—these measures in most 
cases suffice to insure relief. Pencillings with the nitrate of silver, 
though ineffective for the purposes of cauterization, often answer a 
good purpose in hastening repair. The prepuce may require division 
or circumcision. 

For grave and extensive ulcerations, accompanied or unaccom¬ 
panied by phagedena or by gangrene, there is no treatment at all com¬ 
parable in value with the hot-water bath of an average temperature 
of 98° F. For the details of this method the reader is referred to 
the paragraph devoted to the treatment of syphilitic chancre. 

Phimosis and paraphimosis, when complicating chancroids, require 
the surgical treatment appropriate for the relief of those conditions. 
For the accompanying adenopathy in chancroid disease, before suppu¬ 
ration has occurred, rest is essential, with laxatives and gentle local 
compression. When there are great heat and tenderness a few leeches 


1 Congres Internat. de Derm, et de Syph., Paris, 1889. 

2 Arch. f. Derm. u. Syph., Erganzungshefte, 1892, p. 41. 


656 


DISEASES OF THE SKIN . 


may be applied. After pus has formed it may be evacuated with the 
aspirator-needle, or by a free incision in the long axis of the swelling, 
followed by curetting the abscess-cavity and by the usual antiseptic 
dressings. Constitutional treatment by iron, quinin, cod-liver oil, and 
the employment of a generous diet with milk, malt liquors, or wines 
are ofteu required in broken-down and debilitated persons. 

The prognosis, in uncomplicated cases, is generally favorable. The 
scar left by a suppurating gland in the groin is indelible, but it becomes 
less and less conspicuous with years. Sloughing and gangrenous sores 
usually leave deforming cicatrices, especially when occurring at the 
apex of the glans, to which they are apt to give a peculiarly truncated 
shape. A just reserve should be made in all cases complicated with 
syphilis or extensive fistulous sinuses, the latter, as mentioned above, 
often persisting for years. 


LEPRA. 

(Gr. Tienpog, scaly.) 

(Satyriasis, Elephantiasis Grecorum, Leontiasis, Lepra 
Arabum, Leprosy. Ft ., Lepre; Ger., Aussatz; Norweg., 

Spedalskhed.) 

Statistical frequency in America, 0.032. 

Lepra is an infectious, parasitic disease of exceedingly chronic course, capable of 
involving all the organs and tissues of the body, and characterized by cutaneous 
pigment-alterations, disordered or abolished sensation, tubercles or other circum¬ 
scribed or diffuse infiltrations, bullae, ulcers, cicatrices, atrophies, destruction of 
deep tissues, loss of the appendages of the skin, and the ultimate production of 
cachexia which usually terminates fatally. 

Symptoms. In whatever form leprosy may ultimately be manifested, 
its appearance is usually preceded by the prodromic symptoms gener¬ 
ally recognized as the precursors of severe constitutional disease. 
These symptoms are: anorexia; chills, alternating with mild or with 
severe febrile attacks; depression; gastro-intestiual disturbance; and 
insomnia. Their duration is exceedingly variable; in some cases 
patients will remember that these or similar symptoms preceded for 
years the earliest outbreak of lepra. In other cases, but a few weeks’ 
interval occurs between the prodromic and the successive stages 
of the disease. It is worthy of note that the character of the prodro- 
mata furnishes no clue to the severity and type of the oncoming dis¬ 
order. The earlier cutaneous lesions of leprosy are tubercular, macular, 
or bullous. They may be coincident or successive, or one or two of 
these types may so far predominate that another may be either alto¬ 
gether wanting, or may possess, in the general pathological history, 
but a trifling significance. It has thus been customary to make an 
entirely artificial distinction between cases of leprosy, by assigning them 
to three varieties—tubercular, macular, and anesthetic. It will be 
understood, then, in separately considering these three forms, that the 
distinction between them is useful simply for purposes of clinical classi- 


NEW-GBOWTHS. 


657 


fication; that mixed cases of the disease occur which it would be diffi¬ 
cult to assign to either variety exclusively; and that each case merely 
represents a predominance of certain lesions at one pathological epoch. 
It should be noted also that the symptoms of leprosy are particularly 
remarkable for their polymorphism, a wide variation often existing 
between the character of two or more lesions which at any given 
moment are apparent. This variation is largely owiug to the fact that 
leprosy is a general and constitutional disorder, the cutaneous symp¬ 
toms of which are simply its surface-markings. 


[A] Lepra Tuberosa. 

(Tuberculated, or Nodulated, Leprosy.) 

Tubercular leprosy commonly begins in the skin with macular lesions, 
which are bean- to tomato-sized, reddish, brownish, or bronze-hued 
patches; roundish, oval, or irregular in contour; and occurring upon 
the face, trunk, or extremities. The skin covering these lesions is 
either smooth and shining as if oiled, or is moderately infiltrated and 
elevated. 

Fig. 80. 



Lepra tuberculosa (after Danielssen and Boeck). 


After a period ranging in duration from weeks to years, tubercles 
rise from these maculations, varying in size from that of a pea to that 
of a nut, though they may be as large as a tomato. They are yel¬ 
lowish, reddish-brown, or bronzed in color, often shining as if var¬ 
nished or oiled, are covered with a soft, natural, or slightly desqua¬ 
mating epidermis, roundish or quite irregular in contour, and are either 
isolated or grouped. Numbers of very small and ill-determined nod- 

42 


658 


DISEASES OF THE SKIN. 


ules may often be recognized bv careful examination of the skin in the 
vicinity of those fully developed. They may be either cutaneous or 
subcutaneous in situation, and be softish or quite firm to the touch. 

The site of predilection of leprous tubercles is the face; and their 
massing in great numbers upon this region produces the characteristic 
deformity of the countenance which has given to the disease one of its 
names, Leontiasis (face of a lion). Iu such faces the tubercles are 
ranged in parallel series above the brows, down the nose, over the 
cheeks, the lips, and the chin (Fig. 80). In consequence of the infil¬ 
tration and development of the lesions the brows deeply overhang the 
globes of the eyes, the eyelids become affected with partial ptosis, the 
lips pout, and the ears are so studded with tubercular masses as to pro¬ 
ject from the side of the head. The trunk and extremities, including 
the palmar and plantar surfaces, are then usually to a less degree 
involved. Occasionally, indeed, with extensive development of tuber- 

Fig. 81. 



Tubercular leprosy (from a photograph ot a leper in the Sandwich Islands). 

des upon the face and ears, there may not be more than from five to 
fifty tubercles upou the rest of the body, and these either widely dis¬ 
persed and isolated, or agglomerated in a single, hard, flat, elevated 
plaque ot infiltration upon the elbow or the thigh. 

With these cutaneous lesions there is often involvement of the 





NEW-GRO WTHS. 


659 


mucous surfaces, especially the velum palati aud the larynx. In the 
case of a leper affected with the tubercular form of this disease, whom 
the author exhibited at the clinic in 1879, 1 there were very marked 
gruffness and hoarseness of the voice, and the larynx and velum were 
studded with pin-head- to pea-sized, ashen-hued tubercles. Others 
may form upon the conjunctiva and the Schneiderian membrane. 

These tubercles may degenerate into ulcers, or may undergo resorp¬ 
tion and disappear, leaving in their place pigmented atrophic depres¬ 
sions, or they lose their shape in consequence of partial resorption. 
A large plaque may flatten centrally until an annular disk is left to 
indicate its former site. 

It should be borne in mind, however, that the course of the disease 
is exceedingly slow, and that years may elapse before these several 
changes are accomplished. The disease, indeed, often appears to be 
quiescent for months at a time, after which, with the occurrence of 
fever, acute or subacute manifestations appear, and a relatively rapid 
progress is made toward a fatal conclusion. Long before the latter is 
reached there are usually, in tubercular leprosy (Fig. 81), intermingled 
symptoms of anesthetic type, such as the occurrence of bullae or of 
anesthetic patches with and without pigmentation. Toward the last 
the mutilations effected by the disease may result (Lepra Mutilans). 
Phalanges of the fingers or toes, whole digits, an entire hand or foot 
may then become partially or wholly detached by ulcerative, atrophic, 
or other degeneration of skin, bones, and ligaments, hastened or not 
by intercurrent attacks of lymphangitis, erysipelas, septicemia, and 
irritative fever. 

The stadium of this type of the disease may extend through ten or 
even more years. After its full development, the peculiarly dejected 
countenance of the leper, with his leonine facies and general appear¬ 
ance of cachexia, is highly characteristic. 


[B] Lepra Maculosa. 

This form of the disease is chiefly distinguished, as its name implies, 
by its macular lesions. These lesions have the general character of 
those described as preceding the appearance of the leprous tubercles. 
They are diffused or circumscribed, roundish or irregularly shaped, 
and in color yellowish, brownish, or bronzed, often shining or glazed. 
They may or may not be infiltrated, and may in the former case be 
slightly raised from, or on a level with, the adjacent tissues. At 
times they appear as lardaceous deposits in the skin, whitish, reddish, 
or even blackish in color, with a telangiectatic border. These patches 
are usually at first hyperesthetic, but finally they become quite insen¬ 
sitive, so that a lancet can be thrust deeply into them without pro¬ 
ducing the slightest sensation. 

The pigment-variations in macular lepra are noticeable. At times 
a distinctly anesthetic patch may readily be limited both by its lack of 

1 Chicago Medical Journal and |Examiner, December, 1879, with [cut showing laryngoscopic 
appearance of larynx. 


660 


DISEASES OF THE SKIN . 


sensation and of normal color; at other times either symptom may 
fail to correspond with the area of involvement defined by the other. 
Thus a palm- to platter-sized, texturally unaltered area over the thigh 
or the belly may suggest a vitiligo by its relatively slight pigmenta¬ 
tion and its distinct contour, beyond which are sepia to deep chocolate 
tints, gradually fading toward some adjacent and similarly involved 
patch. Yet this area will often differ materially from that of vitiligo 
in other respects. Every inch of the former may be totally insensitive 
to the prick of the lancet, and, moreover, be of a dull, tawny, yellow¬ 
ish, or parchment-like hue, never having the peculiar milky-white 
tinge of vitiligo. Again, this anesthesia may extend widely beyond 
the line traced by the pigment-anomaly, or even within the latter may 
vary, islets of skin capable of perceiving sensation being in cases 
here and there discernible. 


[C] Lepra Anesthetica. 

This cliuical variety, as has been described, may be commingled in 
its symptoms with each of the other types. With and without such 
commingling, however, there is commonly noted first an eruption of 
bullae, bean- to large nut-sized, with a roof-wall constituted of the 
entire thickness of the epidermis, filled wirh a clear-tinted or blood- 
mixed serum, occurring usually upon the extremities. The cicatrices 
which follow these bullae are atrophic patches, each often far greater 
in extent than the base of the original bleb, whitish, shining, glazed, 
or better described as of a tint suggesting the hue of mica; circular 
in outline, forming also the dumb-bell figure by coalescence or juxta¬ 
position. These cicatrices are always anesthetic, and they may coexist 
with macular and anesthetic patches upon the trunk or other portions 
of the body. Neither those of the one class nor of the other, however, 
are disposed over the surface of the body in lines, bands, or curves 
corresponding with the distribution of the cutaneous nerves. The 
greatest irregularity is displayed; asymmetry is the rule. Occasion¬ 
ally, however, the ulnar and other nerves accessible to the touch are 
recognized to be tumid, tender, insensitive, or as rigid as indurated 
cords. General atrophic cutaneous symptoms follow; the skin becomes 
dry and harsh; there is manifestly little or no sebaceous product; the 
sweat is scanty; the muscles atrophy; the hairs fall; the lymphatic 
ganglia enlarge; the skin of the face seems tightly stretched over the 
bones. As a result of deformiug atrophy of the eyelids, epiphora 
and consequent orbicular changes ensue, and the parted lips permit 
constant escape of saliva. The fingers are half-drawn into the palm 
of the hand; the nails are distorted, and, later, ulceration occurs 
(Fig. 82). 

The ulcers are irregular, oval, roundish, linear; covered with thin, 
blackish, flattened, tenacious, never rupioid, crusts; their bases are 
soft; their floors covered with a pultaceous debris often mixed with 
blood; the whole usually insensitive to every foreign body and external 
application. Lastly, the symptoms of lepra mutilans may occur, digits, 


NEW-GROWTHS. 


661 


or portions of the carpus, metacarpus, or corresponding parts of the 
foot, being detached from the body. 

Death may ensue, at any time during the course of the disease, from 
septicemia, exhaustion, or any of the iutercurrent. affections to which 
a patient in such a condition is particularly disposed. Thus, a leper 


Fig. 82. 



Anesthetic leprosy with mutilating results (from a photograph taken of a leper in the 
Sandwich Islands). 


was accidentally choked to death in San Francisco by some perversion 
of the function of deglutition. The disease, however, in the anesthetic 
form is said to last from eighteen to twenty years, and is thus less 
rapidly fatal than the tubercular variety. 

Considering the several clinical varieties of leprosy named above, 
and the mixed forms resulting from a commingling in some cases of 
the features of all varieties, the result is merely an analysis of the 
symptoms in an enormous clinical field. There are not, in fact, any 
forms or varieties of this disorder; there is but one disease which 
exhibits itself in widely differing manifestations, and these at one time 
and in one country assuming a predominant phase, while with a different 
environment and in another race other phenomena appear. Thus, lepra 
tuberosa is reported in from 50 to 75 per cent, of patients affected with 
the disease in the north of Europe, and in from 10 to 20 per cent, of 
those in tropical countries; while anesthetic lepra in the geographical 
limits last named is represented by two-thirds of patients, and in 


662 


DISEASES OF THE SKIN. 


northern latitudes by less than one-third. “ Mixed forms ” are less 
often reported than others, but as a matter of fact are the more often 
observed. The reason for this apparent anomaly lies in the fact that 
really pure cases of any form are actually rare. It is best to look 
upon the expressions of lepra, as it is accepted to regard the phenom¬ 
ena of syphilis : in each there is a single morbid principle; there are in 
both no true varieties; and the external symptoms differ chiefly be¬ 
cause of special accidents of environment, of race, or of individual 
peculiarities. 

Looking at the variant symptoms of lepra, a wide range occurs in 
all stages. In the evolution of the disease there is a usual order of 
fever, eruptive symptoms, and ulcerative or destructive sequels. In 
the prodromic period there are often chilliness, profuse diaphoresis, 
insomnia, inappetence, diarrhea, vertigo, and even a bullous efflores¬ 
cence upon the surface. These prodromata are rarely wanting, and, 
after lasting for weeks, months, or years, are followed by sensations 
of chilliness, with remitting or intermitting febrile symptoms, the tem¬ 
perature rising from 100° to 105° F. The tongue becomes of a red¬ 
dish hue, the listlessness and sluggishness continue, and the typical 
cutaneous lesions of the disease (leprous spots) appear, commonly on 
some portion of the face, with or without oedema. In some cases the 
prodromic symptoms and fever and chilliness are either absent or, 
what is more probable, are unnoticed, and then the disease may be first 
recognized by pains of a lancinating character, tenderness, and aching, 
especially along the course of the ulnar, peroneal, median, saphenous, 
or other nerves; or the result may be hyperesthesia, anesthesia, or 
pricking, tingling, and similar sensations in regions supplied by special 
nerves. The greatest variation is observed in the length of time dur¬ 
ing which these early symptoms, with more or less vagueness of expres¬ 
sion, exist. Later, tubercles, nodules, bullpe, macules, hyperesthetic 
and anesthetic patches appear with gradual development of other and 
non-cutaneous symptoms, paralysis, exaggerated tendon-reflexes, and 
atheromatous papules upon the palpebral membranes and cornea. At 
times there results an ulcerative keratitis; nodules appear over the chest, 
genital regions, and extremities, as well as upon the mucous surfaces of 
the mouth and respiratory tract. The voice becomes raucous, while 
recrudescences of the disease occur either along the one (tubercular) 
or the other (anesthetic) line toward the final stages of degeneration 
and mutilation. 

The disease is seen in all typical forms, even in regions where lep¬ 
rosy is least prevalent. There may be a genuine leprous pachydermia 
with enormous increase in the volume of the hands and feet, accom¬ 
panied by severe onychia and paronychia, and deep ulcerations about 
the nails. In some cases tumefaction of an entire limb results, strongly 
resembling an elephantiasis. The nose may be stuffed with leprous 
tubercles; and a large number of cutaneous symptoms of the most 
varying type develop in and upon the leprous skin as the result of 
secondary infection, of accidents, or of invasion by pus-cocci, etc., for 
it must be remembered that in the mass of cases the leprous belong to 
the filthy and impoverished classes of society. Thus, there are often 


NEW-GROWTHS. 


663 


developed eczemas, erythematous and achromic and hyperchromic spots 
and disks, annular lesions resembling those seen in syphilis, bullae 
rapidly becoming gangrenous (erytheme polymorphe lepreux, bulleux, 
et escharotique, of Leloir), noduies of the,usual size and hue of those 
in lepra (pin-head- to nut-sized, pigmented, reddish-brown, copper- 
tinted, glazed, shining, as if oiled), and enormous infiltrations within 
and below the derma, even the production of large tumors of leprous 
tissue. 

The generative apparatus may seriously be involved, the uterus, 
Fallopian tubes, and ovaries being the seat of leprous nodules or dif¬ 
fuse lepromatous infiltrations; as may be also the testicles, prostate 
gland, and penis. The breasts are often 
stuffed with tubercles; but they, as also the 
other organs named, may simply waste un¬ 
der the influence of the disease. The sexual 
power is retained longer than is commonly 
believed. In the colored races the eruptive 
symptoms are tinted in yellowish and red¬ 
dish shades, a result due to contrast with the 
hue of pigmented skins. 

Etiology. Leprosy is a contagious and 
infectious parasitic disorder produced by the 
bacillus leprae. Secretions of a leprous pa¬ 
tient containing these bacilli or their spores 
are the usual vehicle by which the disease is transmitted from man to 
man. The question of the inheritance of leprosy may be regarded to¬ 
day as in much the same position as that relating to the inheritance 
of tuberculosis; no fetus, no newborn living child has been known 
to exhibit the symptoms of either disease. Men are more often affected 
with the disease than women. Infection is more common after the 
second decade, though children are occasionally found among its 
victims. 

The geographical distribution of leprosy is widely extended. In 
countries where it has not previously existed its appearance is invari¬ 
ably due to the infection of sound individuals by lepers first exhibiting 
symptoms in a country where the disease is prevalent. Neisser form¬ 
ulates the law of its prevalence by stating that the number of lepers 
in any country bears an inverse ratio to the laws executed for the care 
and isolation of infected persons. 

The disease exists in the interior and throughout the seaboard regions 
of Africa, including Egypt; in Arabia, Syria, Persia, China, Japan, 
and India; in the islands of the Mediterranean, Black, Caspian, and 
China Seas, of the Indian Ocean, and of the Australian Archipelago; 
in Norway and Sweden, Iceland, Russia, Turkey in Europe, Spain, 
France, Portugal, Greece, and Italy; and sporadically in Germany, 
England, and the smaller European States; in North, Central, and 
South America, and the West India Islands. In America special 
attention has been directed to the subject, by the existence of the dis¬ 
ease in an epidemic form in the Sandwich Islands, with which the 
Pacific States sustain close commercial relations; by its occurrence 


Fig. 83. 



Larynx of patient affected with 
lepra tuberculosa (one of the au¬ 
thor’s cases). 


664 


DISEASES OF THE SKIN . 


among Chinese immigrants in San Francisco and other portions of 
California; by cases reported from New Orleans by Burns, 1 Bemiss, 2 
Jones, 3 and Solomon, 4 and by various reports of sporadic cases observed 
in Minnesota, Maryland, Illinois, Nebraska, New York, and other 
States of the Union, by Gronvold, Hoegh, Bendeke, Roh6, Piffard, 
Elsberg, Atkinson, the author, and others, collected by the Committee 
on Statistics of the American Dermatological Association, and presented 
to that and other bodies in special papers. White and Graham, of the 
same committee, have also contributed to the history of the colony of 
lepers that has long existed in Tracadie, in the province of New Bruns¬ 
wick. 

With this wide geographical distribution, the disease exists endem- 
ically in certain countries, and also in certain regions of the same 
country, with greater frequency than in others. All attempts, how¬ 
ever, to connect its origin with malaria, with a residence near inun¬ 
dated sea marshes, with the ingestion of a diet consisting largely of 
fish, or of a diet from which salt has largely been excluded, have 
failed of any recognized success. The disease, however, seems to 
spread more rapidly in damp and cold, or warm and moist climates 
than it does in temperate countries. It is true that probably the 
larger number of all living lepers are those who have been poorly 
fed and otherwise subjected to the most insalubrious of influences, but 
the disease also attacks, though far more rarely, persons whose social 
position and hygienic surroundings are of the best. It occurs in both 
sexes—though more frequently in males—and at all ages; and, despite 


Fig. 84. Fig. 85. 



Larynges of lepers affected with lepra tuberculosa (Elsberg’s cases.) 


all efforts to show the contrary, bears no relation to syphilis. Lepers, 
however, become syphilitic if infected with that disease, precisely as 
they may and do acquire variola, varicella, morbilli, erysipelas, and 
phthisis. The Hebrew Scriptures are often interpreted as showing 
that the disease among the Jews iu Palestine was regarded by them as 
contagious and so treated. The modern student of these writings 
will, however, be convinced that this interpretation is erroneous. The 
leprosy of the book of Leviticus not only includes lepra, as that term 
is understood to-day, but also psoriasis, scabies, and other cutaneous 
affections. The leper, in the eye of the Mosaic law, was ceremonially 


1 Arch, of Med., December, 1881. 
3 Ibid., March, 1878. 


2 N. O. Med. and Surg. Journ., April, 1880. 
4 Trans. Louis. State Med. Assoc., 1879. 



NEW-GROWTHS. 


665 


unclean, and capable of communicating only a ceremonial uncleanness. 
Several of the narratives contained in these books bear witness to the 
fact that the Oriental leper was occasionally seen doing service in the 
court of kings, and even in personal communication and contact with 
officers of high rank. 

Pathology. The bacillus of leprosy is a delicate rod-shaped para¬ 
site from one-half to three-fourths of the diameter of a red blood- 
corpuscle in length, and about one-fifth as broad as long. The bacilli 
of leprosy are morphologically almost identical with those of tubercu¬ 
losis, but are found in affected 
tissues in vastly greater numbers, 
appearing usually in clumps, and 
responding more promptly to stain¬ 
ing and decolorizing agents. These 
microorganisms have been found 
in nearly all the tissues of the body 
and especially in the skin, mucous 
membranes, interstitial tissue of 
the peripheral nerves, in the car¬ 
tilages, cornea, spleen, liver, lym¬ 
phatic glands, sebaceous glands, 
and hair-follicles, also less abund¬ 
antly in the testicles, spermatic 
cords, ovaries, and walls of the 
blood-vessels. They do not occur 
in the muscles, spinal cord, bones, 
or joints, and are wanting in many 
secondary inflammatory lesions, 
such as bullae on the surface of the skin. They are very rarely found 
in the epidermis, and though they have been seen in the blood, their 
discovery in that fluid has not been confirmed by several investiga¬ 
tors. The bacilli are not found in physiological secretions unless 
these be pathologically altered by coming from an organ or membrane 
affected with leprous infiltration. 

The parasites are most numerous in comparatively recent but fully 
developed nodes of the skin. Such a node on section shows in the 
centre a brownish mass or “ globus,” which sometimes can be shaken 
out of the surrounding tissue, and which on examination proves to be 
composed almost entirely of masses of bacilli. Even in the diffuse form 
of infiltration the bacilli are usually found in groups or masses. Accord¬ 
ing to Hansen and Looft, the bacilli are almost invariably situated 
within a u lepra cell,”or occasionally in endothelial cells of the vessels, 
or in white blood-corpuscles. Unna, on the contrary, thinks the 
bacilli are entirely without cells. Most investigators agree with the 
observations first cited, but think it probable that there are a few free 
bacilli, and also some in the lymph-channels. 

Unlike the bacilli of tuberculosis, those of leprosy apparently do 
not live or grow outside the living human body. Campana and Ducrey 
obtained cultures, as they supposed, of the lepra bacillus, but did not 
verify their results by inoculation, experiments, and their conclusions 


Fig. 86. 



c T 

Bacilli of leprosy: a, epithelial scale. About 
X 1200. (From one of the author’s patients.) 


666 


DISEASES OF THE SKIN. 


are not generally accepted. Practically, the bacillus has not yet been 
cultivated. Attempts to inoculate lower animals with leprous tissue 
have given no definite results. Numerous attempts have been made to 
inoculate human beings with leprosy, but the disease developed in only 
one of the inoculated individuals, and as he came of a leprous family 
the result cannot be considered conclusive. 

The introduction into living tissues of leprous tissue containing 
bacilli results simply in a local inflammation such as would be pro¬ 
duced by the introduction of any inert substance. In such experi¬ 
ments the leprous tissue, which had hardened for months in alcohol, 
was equally effective with the fresh tissue. Besnier and others believe 
that the bacilli die with the tissue in which they have lived, and thus 
account for the failure of culture- and inoculation-experiments. The 
slight viability of the bacilli is largely responsible for the usual 
benignity and slow progress of the disease. 

In tubercular leprosy the chief histological changes are seen in the 
corium, the uodule being made up chiefly of a granulation-tissue similar 
to that seen in lupus and syphilis, but the leprous tissue is less vascu¬ 
lar and consequently undergoes formative and retrogressive changes 
less rapidly ; the cells are larger than in the other two diseases named, 
and do not form in nests, as in lupus. The cells, which probably orig¬ 
inate in endothelial cells of the vessels, or in migrated cells, are seen 
in varying sizes and usually filled with bacilli to form the “ lepra 
cells.” Giant cells are also seen. 

The infiltration may be diffuse as well as nodular, and is most 
marked at first about the vessels, glands, and follicles. Later it may 
obliterate the papillae and their line of union with the rete, and extend 
to the subcutaneous tissue. The external and middle coats of the 
• vessels are infiltrated and thickened and their lumen narrowed. The 
sebaceous and coil-glands and the follicles are involved early, at first 
undergoing infiltration and hyperplasia, later degenerating and dis¬ 
appearing. The epidermis is involved secondarily only, and may be 
thus thinned and atrophied or broken in the formation of ulcers. 

In macular and anesthetic leprosy Hansen and Looft 1 state that 
u the macules are, like the nodules, leprous infiltrations of the cutis, 
consisting of round epithelioid and spindle cells, the latter being more 
numerous the greater the age of the macule. These infiltrations appear 
to proceed from the vessels. Lepra-bacilli are always present, but are 
most numerous in the younger macules. In the young, not as yet 
anesthetic macules the nerve-twigs appear unchanged; in the older 
ones they are usually affected.” The essential nerve-changes are an 
infiltration of cells containing bacilli within the external sheath and 
between the nerve-fibres, resulting in a gradual disappearance of the 
latter as a result of pressure produced by the great increase of intersti¬ 
tial connective tissue. The irritation of the nerve-fibres in the early 
stages accounts for the pains and hyperesthesia; the nerve is also 
increased in size, often to a marked degree. Later there are atrophy 
and shrinking of the nerve, of which many of the original fibres have 


1 Leprosy in its Clinical and Pathological Aspects, English translation by Walker, London, 1895. 


NEW-GROWTHS. 


667 


been destroyed and replaced by connective tissue, with resulting anes¬ 
thesia. The peripheral nerves are thus frequently affected, but in the 
brain and cord leprous changes have not been demonstrated. In a 
few cases of anesthetic leprosy degeneration and atrophy of the poste¬ 
rior columns, posterior roots, and spinal ganglia have beeu demon¬ 
strated, as well as other changes probably due to an associated tuber¬ 
culosis which is not infrequently present. 

Regarding the disappearance of leprous lesions and tissue, Hansen 
and Looft say that in both the nodular and the maculo-anesthetic 
forms “ the bacilli in the leprous products break up into granules 
which finally disappear, and there remains of the leprous products 
only a scar in which nothing leprous can be recognized. Occasionally 
this takes place in all the affected parts, and there remains only a wide¬ 
spread anesthesia, the result of the nerve-affection; and in the maculo- 
anesthetic form this is the regular termination of the disease. In both 
cases the leprosy is completely healed.” 

Diagnosis. In well-marked cases the recognition of leprosy is sim¬ 
ple. In its prodromic periods no suspicion of its existence would be 
awakened in countries where the disease is not endemic. 

From syphilis, which is also a disorder the lesions of which are 
polymorphic in character, lepra can be distinguished by its much greater 
chronicity; its larger and brownish-yellow, glazed tubercles; its fre¬ 
quent hyperesthetic and anesthetic symptoms; its bullous lesions, rare 
in acquired syphilis; the far more extended areas of its erythematous 
macules; its blackish crusts, lacking the rupioid aspect of those in 
syphilis; its leathery, mica-tiuted cicatrices; and the characteristic 
leonine facies of its tubercular forms. 

Morphea and vitiligo are both unattended by constitutional changes, 
and more particularly exhibit no hyperesthetic or anesthetic symptoms 
in the affected patches. The atrophic and often deeply pigmented con¬ 
dition of the skin in the final stages of pityriasis rubra, associated 
with the emaciation and febrile condition of the patient, might for a 
time mislead the observer who had not a full history of the case. 
Multiple sarcomata, especially upon the face, are followed by much 
more rapid degeneration and a fatal result. 

All lesions of erythema multiforme can readily be distinguished from 
those of lepra by the absence of hyperesthetic or of anesthetic symp¬ 
toms. Syringomyelia is differentiated by its display of lesions only 
in regions where there is also muscular atrophy, by the much greater 
extent and lack of definition of areas of perturbed sensation, by 
diminution of the tendon-reflexes, which may be exaggerated in lepra, 
by a marked predominance of symptoms in the upper as distinguished 
from the lower extremities, and by the frequent presence of scoliosis. 
The nodules of lupus are not symmetrical, are far softer, and are much 
more often grouped than those of lepra. Further, they never have 
the size of the larger leprous tubercles, and never have the peculiar 
pigmented, brownish, and oiled, or varnished aspect of leprous nodules. 

Finally, the diagnosis of leprosy requires not only clinical symptoms, 
but also a definite contagion. Whether a history of transmission from 
one individual to another be or be not obtainable, it is certain that no 


668 


DISEASES OF THE SKIN. 


person ever manifests leprous symptoms who has not been infected by 
some other individual who is a victim of the disease. 

Treatment. One of the most important considerations relative to 
the therapy of leprosy is that requiring the segregation and isolation of 
all lepers from contact with the uninfected. In some countries, those 
particularly where leprosy prevails, wholesome laws enforce this sepa¬ 
ration of the infected, and charitably provide also for the care of the 
wretched victims of the disease. In America, where leprosy, in con¬ 
sequence of its great rarity, has not yet awakened the attention of 
legislators beyond the point of forbidding the importation of infected 
persons, the proper care of lepers in a community only too ready to 
take alarm even at the name of the disease is a serious matter. Many 
of our public hospitals for the care of the sick poor refuse to receive 
lepers. In several States of the Northwest the officers of health-boards 
are powerless to make proper provision for the care of a leper whose 
case is brought to their attention. 

No remedies are known to have a directly curative effect in leprosy. 
As a consequence, the treatment of the disease is that suggested to the 
intelligent practitioner by the indications in each case. Most impor¬ 
tant, when the patient happens to reside in a district where the disease 
prevails, is an immediate change of residence and climate; the adoption 
of a highly nutritious diet; and the exhibition of roborant remedies, 
including steel, quinin, cod-liver oil, and often the moderate use of 
wines and malt liquors. The cinchonas and salicylates are indicated 
in morbid thermic conditions. Mercury, arsenic, the iodid compounds, 
hoang-nan in pills of 3 grains (0.266); creosote, in half-drop doses 
(0.033); the oil of cashew-nut, gurjun balsam, chrysarobin, pyrogallol, 
resorcin, 10 per cent, solutions of salicylic in oleic acid (Arning); ich- 
thyol, and chaulmoogra oil, internally and externally, have all been 
employed with varying success by different practitioners; but an 
unprejudiced review of the maximum of results thus obtained will 
establish the conviction that no one of the remedies named may be 
regarded as in any sense possessing a controlling influence over the 
disease. Most of them have been employed by skilled physicians, 
sufficiently wise to enforce simultaneously the most generous tonic 
regimen, thus clouding with some doubt a belief in the part played by 
the medicament in the production of the result. In the case of a leper 
and his little daughter in Nebraska, who were treated for some time 
with chaulmoogra oil, very marked benefit was noticeable in the course 
of a few months, a result probably due, in this instance, to the salubrious 
surroundings of a farm in the country. 

Every secreting ulcer and open surface in the person of a leper 
requires prompt and absolute disinfection with a solution of bichlorid 
of mercury, in order to destroy the bacilli that are commonly present. 
Baths are of great value in all these cases, and they may be medicated 
with any desirable substance. It should not be forgotten in the local 
treatment of leprous tubercles, ulcers, and other lesions, that however 
foreign the disease may be to the climate of the United States, the sim¬ 
ple principles, dermatological and surgical, by which one is governed 
in ordinary cases, are not to be forgotten. Disinfectants, carbolic and 


NEW-GROWTHS. 


669 


boric acids, bland unguents, inunctions, and local stimulants of the 
skin are as useful, when properly applied to the leprous, as to the 
syphilitic, the cancerous, and the scorbutic patient. 

Prognosis. The future of the leper is indeed dark. The disease is 
malignant in character, and, however protracted, a fatal result is 
usually inevitable. Still, with a change of climate and improved 
hygienic conditions, much may be accomplished. There can be no 
question that the Scandinavian lepers who have removed to the United 
States have been greatly benefited by the change. This, indeed, was 
the opinion of the late eminent Professor Boeck, who, during his useful 
career, visited Minnesota, and there studied the history of eighteen 
leprous immigrants who had come from Norway. He believed, in 
fact, that the change in some cases would work a complete arrest of 
the disease. A careful study of the history of leprosy in America will 
induce the belief that such a favorable result can be anticipated after 
residence in the Northwestern States, as well as in other portions of 
the country. 

The Saktian Disease (Taschkent-geschwur) is an infectious 
granuloma, described by Heiman, and microscopically examined by 
Rudniew. It occurs in Taschkent, or Tashkend, an important market- 
town of Asiatic Russia, west of the Caspian Sea. The disease affects 
the face, the upper extremities, and the trunk, avoiding always the 
palmar and plantar regions. Reddish macules develop here into 
nodules, which desquamate, coalesce, degenerate, and leave crusted 
ulcers, which may cicatrize. 


CARCINOMA. 

(Gr. naptavog , cancer.) 

Carcinoma of the skin is a term employed in the designation of the several forms of 
malignant tumors which are in part constituted of epithelial new-growth, either 
occurring primarily in the cutaneous tissues or developing there atter the involve¬ 
ment of other organs. 

The term cancer has both loosely and definitely been employed in 
the designation of malignant cutaneous tumors. Every cancer of the 
skin is, according to some authors, necessarily both alveolar and epithe- 
liomatous in structure; while others distinctly recognize forms of cancer 
which are not epithelial. In these pages, for the sake of retaining a 
convenient clinical distinction, the term carcinoma, or cancer, is used 
generically to include epithelial, fibrous, and melanotic neoplasms. 
It will be understood, however, that in the structure of all these new- 
formed groups epithelium plays an important part. 


670 


DISEASES OF THE SKIN. 


Epithelioma. 

(Epithelial Cancer, Carcinoma Epitheliale, Rodent 
Ulcer. Ger ., Epithelialkrebs; Fr ., Cancroide.) 

Statistical frequency in America, 0.863. 

Three varieties of epithelioma are recognized—the superficial, the 
deep, and the papillary. 

Superficial, or Discoid, Epithelioma is usually first displayed 
upon the sound skin in the form of one or of several, pin-head-sized 
papules, flat infiltrations, disks, or nodosities of a dull-yellowish, 
reddish, grayish, or dirty wax-like hue. The growth may also have 
its origin in previously existing skin-lesions which are both numerous 
and different from one another. Among the latter symptoms may be 
named: fissures and excoriations (especially those long teased by caus¬ 
tic applications); warts, nevi, acneiform and molluscoid lesions; and 
the dry or greasy epidermal scales often seen at the orifices of the 
sebaceous glands in the faces of the aged. The outline of the newly 
developed growth as a consequence varies, being roundish, linear, or 
irregular. As a result of accident or traumatism (especially scratching 
and picking, which the history of a large proportion of all cases includes), 
there forms a superficial excoriation, which may be covered with a sero- 
sanguineous crust, after the desiccation of its scanty and ichorous secre¬ 
tion. In the progress of its development it is often noticed that new 
foci of disease appear in the immediate vicinity of the first, repre¬ 
sented by subepidermic, indurated nodules, or superficial “pearls” 
resembling milia, whitish and lustrous, with marked tendency to vas¬ 
cularization, exfoliation, and superficial ulceration. 

A frequent result is the ultimate formation of an ulcer, called the 
Rodent Ulcer (Jacob’s Ulcer, Ulcus Exedens, Noli-me-Tangere, 
Cancroid Ulcer), whose characteristics are marked. These character¬ 
istics are a roundish, fissured, or slightly angular contour, and a red¬ 
dish or reddish-brown, irregular, granulating, and mammillated floor, 
covered with a thin, translucent, viscid serum, which, in drying, sug¬ 
gests the effect of a varnish over the part. The edges of the ulcer are 
clear-cut, indurated, usually well-attached, and, seen in horizontal 
profile, irregularly indented. The symptoms are slight at first; the 
lymphatic ganglia and general health being unimpaired. Its site of 
election is the face, particularly the eyelids, nose, temples, and lips, 
though the genitalia, the hands, and the feet may be affected. Of two 
hundred and fifty cases collated by Heurtaux, in one hundred and 
ninety the face was attacked. 

Some English writers still describe the rodent ulcer as distinct from 
epithelioma, chiefly by reason of its individual peculiarities. Patho¬ 
logically no distinction can be established between the two. The clin¬ 
ical features upon which this distinction is based are: the slow or 
intermittent development of rodent ulcer; its tendency to destroy, as 
it extends, all the tissues within reach; its failure to implicate the 


NEW-GROWTHS. 


671 


system by secondary deposits or metastases; its rounded and often 
widely everted edges, or, better, lip, often distinctly vascularized; its 
gouged floor exhibiting unequal levels; its very slight tendency to 
granulation; and its feeble or negative attempts at repair. All these 
symptoms are those of epithelioma, if one chooses to employ that 
term in its large and proper sense. The rounded or oval excavation, 
often exceedingly clean-cut, at times with a corded and whitish rim, 
producing, if any, little pain, is characteristic of the rodent ulcer, 
yet in its extension it may exhibit all the symptoms of a deep epithe¬ 
lioma. 

Under the title u Crateriform Ulcer,” Hutchinson 1 describes a 
form of epithelioma distinguished chiefly by the rapidity of its inva¬ 
sion. Its onset is by the formation of a roundish or conical mass 
which rapidly exhibits ulceration, a central crater forming with exceed¬ 
ingly dense walls. 

The subsequent course of the lesion varies, its evolution being gen¬ 
erally slow and accomplished in years. Sometimes having attained a 
maximum of size, the ulcer, if unmolested, long persists without appre¬ 
ciable change. In other cases the base cicatrizes and the epithelioma 
completely exfoliates, leaving an outlying linear ulceration which may 
persist or spread. In yet other cases, after a persistence of from ten 
to twenty years, the ulcer may spontaneously close and the disease be 
at an end. Sometimes the ulceration is very superficial and slowly 
spreads in circles, segments of circles, or in irregular gyrate outlines, 
the older portions healing and cicatrizing while the border advances. 
Such lesions may cover considerable areas of the body and closely 
resemble some serpiginous lesions of syphilis and lupus. In many of 
the cases the papillomatous element is more or less marked. To this 
form of superficial discoid epithelioma the name Paget’s Disease is 
sometimes applied, as the process is practically the same as that which 
attacks the nipple and breast. Finally, any one of the destructive 
and malignant cancerous processes may be awakened, and the epithe¬ 
lioma be thus transformed from the type of the superficial to that of 
the deep variety of the disease. 

Deep or Tubercular Epithelioma. This variety may originate 
in the manner already described, or may be from the first characterized 
by its specific features. It commonly begins by the formation of 
roundish, very firm, pea-sized nodosities closely set together in the 
skin and subcutaneous connective tissue, or be thus situated and well 
projected from the surface. In the course of months and years these 
nodules develop to form a nut- or even a small egg-sized tumor, round¬ 
ish, dark-reddish in color, and delicately vascular on its surface. This 
tumor may be a deep flattish or globoid development within the skin; 
or be a well-defined nodule attached to it; or (and this is a common 
form) be a dense, thick, flattened plaque, one inch or more in diameter, 
its walls steeply descending to the sound skin on either hand or moder¬ 
ately everted; its centre depressed by atrophic changes; its surface 

i Transactions ot the London Pathological Society, 1889, p. 275. 


672 


DISEASES OF THE SKIN. 


shining, waxy, pinkish or red, with ramifying capillaries. “ Satel¬ 
lites” may form in its vicinity. 

Degeneration of these forms produces in the course of time an ulcer 
either quite like that described above, or one which deeply and destruc¬ 
tively encroaches upon the tissues beneath. In advanced cases the 
latter ulcer is irregular in contour, with a clean-cut, everted, indurated 
lip; eroded and u gouged,” hemorrhagic and granulating floor; thin, 
viscid secretion which is foul and purulent at times when the resulting 
destruction is rapidly accomplished; and a deep attached base which 
may be perforated by a crateriform exulceration extending down to or 
through muscles, fasciae, cartilage, and bone. The lymphatic ganglia 
become simultaneously involved, and a general cachectic condition is 
fully established. Death may ensue from marasmus, exhaustion, or 
hemorrhage, in the course of several months or from one to three years. 

Papillary Epithelioma. The cancer in this variety assumes 
the form of a malignant papilloma. In these cases a pedunculated 
or sessile, narrow or broad-based, smooth-capped, or spongy and ver¬ 
rucous vegetation is attached to the skin upon which it forms. It may 
originally be as small as a pea, but usually it increases considerably 
in volume, being not rarely pigeon’s-egg- and turkey’s-egg-sized. The 
surface is either dry, reddish-yellow, smooth, and lustrous; exfoliating, 
and secreting an offensively smelling sanguineous or translucent fluid ; 
or is moist, granulating, filamentous, and intermingled with hairs, as 
when it occurs upon the bearded cheek. Degeneration occurs later, 
fissures forming first; subsequently there appear superficial, and finally 
deep, ulcers which ultimately assume all the features of the epithelioma 
described above. 

Singular varieties of papillary epithelioma are occasionally seen 
upon the head. The entire face of an elderly man may be covered 
with rings (having a diameter of an inch or more) the centre of each 
of which is largely composed of densely indurated cicatricial tissue. 
The borders of these rings are often built up of a reddish-brown, 
warty, cancerous growth, secreting slightly, here and there commingled 
with the hairs of the face (beard, eyelashes, brows), and elevated one- 
fourth of an inch or more above the general level of the integument. 
Growths of this sort are not rarely seen upon the back of the hand, 
over the forearm, and on the leg. Distinctly circinate forms are pro¬ 
duced, the vegetation here having a dryish appearance, a brownish-red 
crust, neither bulky nor uniform, a cicatriform or infiltrated central 
area, and an exceedingly slow course. In some cases the epithelioma 
forms a soft, hemispherical, small nut- to egg-sized tumor, which, upon 
pressure discharges numerous convoluted plugs, composed of epithe¬ 
lium, fatty masses, and a purulent secretion. The bases of these soft 
masses are remarkable for the ease with which they can be curetted 
and thus radically removed. 

A careful study of well-marked cases of papillary epithelioma indi¬ 
cates clearly that while ulceration often results, the centre of the mass 
breaking down and furnishing a typical cancerous excavation, with 
hard and rounded or oval border, uneven base, irregular granulating 


NEW-GROWTHS. 


673 


floor, and offensive discharge, the picture may be wholly different. 
Often the wholly superficial process extends widely over the brows, 
cheeks, and chin, interspersed with raised cicatriform areas, suggesting 
that ineffectual attempts had been made to check the disease by sur¬ 
gical measures. These apparently atrophic disks, mingled with vas¬ 
cular, florid, fungiform, pyriform, and oddly shaped outgrowths, are 
really cancerous infiltrations of the type of discoid epithelioma. They 
may be seen gluing the lobe of the ear to the cheek (Fig. 87), or evert- 


Fig. 87. 



Superficial papillary epithelioma of the face, with agglutination of the lobe of the ear to the 
cheek. The central portion of the right cheek is the seat of a cicatriform infiltration. (From 
a photograph.) 

ing the lower lid, even when superficial papillary vegetations are the 
predominant features of the disease. 

Epithelioma of the skin occurs also with multiform features, 
almost as numerous as the several different lesions from which a 
cutaneous cancer may take its origin. Thus, a wart, a a button, 
a vegetation, a crack, an erosion, may result in a fissure which bleeds 

43 




674 


DISEASES OF THE SKIN. 


easily and refuses to heal. After a persistence for months or for 
years there forms an epithelioma, assignable to one of the clinical 
varieties described above. In other cases there may be a number of 
greasy scales upon the skin-surface resembling those seen in a well- 
marked seborrhea sicca, and in one or two spots; the removal of these 
scales offers to the eye a superficial erosion implicating the derma, 
bleeding freely, and, when undisturbed, crusting and slowly spreading 
under the crust rather than healing. In yet other cases a thin pellicle 
of apparently loosened epithelium, looking like a papery crust, is found, 
when removed, to cover three or more shallow ulcers, unexpected and 
hidden from view by the tenacious pellicle which had protected them 
and beneath which they had indolently and painlessly developed. 

These varieties or types of epithelioma may coexist in different por¬ 
tions of the same integument, or the one may develop from the other, 
a malignant papillary growth springing from a superficial or a deep 
cancerous infiltration. Familiar examples of the disease are seen upon 
the eyelids and contiguous portions of the nose; the cheek and the 
lower eyelid, the latter being often drawn into ectropion by a cicatri- 
form bridle or band; the nose or lip and adjacent mucous or osseous 
tissue; and the glans and prepuce where the vegetating forms are of 
more frequent occurrence. The vast destruction wrought by the widest 
development and consequent degeneration of epithelioma is sufficiently 
recorded in the annals of both medicine and surgery. A woman sixty- 
four years of age was exhibited at the clinic, in the centre of whose 
face an ulcerating epithelioma had left a wide chasm, after destroying 
three-fourths of the nose and upper lip, and the hard palate with all 
the upper teeth and the antrum. The bones at the base of the skull 
were exposed. This case illustrated well the occasional remarkable 
tolerance by the system of the profoundest encroachments of epithe¬ 
lioma. She was then digesting and assimilating food with fair profit, 
and suffered chiefly from pain. She did not die until several months 
had elapsed, and then only as the result of hemorrhage from an ulcer¬ 
ative opening into one of the large arteries. 

Cancer of the Head. In this region of the body nearly three- 
fourths of all cancers of the skin are recognized. Upon the brow, the 
alse of the nose, the temples, cheeks, chin, scalp, or other part, the 
disease may begin either upon or beneath entirely normal skin, or in 
that which has pathologically been changed. The origin of the disease 
is usually ascribed to the picking, scratching, or shaving over, a seba¬ 
ceous wart in an old man; or in similar traumatisms of acneiform, 
seborrheic, or furuncular lesions in either sex. In other cases the 
dermatologist, consulted with reference to some other ailment of the 
skin, can recognize, in persons of the age most liable to such accidents, 
one or several pin-head-sized or larger milium-like nodules, clustered 
about the temples or the nose, that indicate'the site of the awakened 
epitheliomatous change. The disease progresses very slowly, spread¬ 
ing superficially along the alae of the nose in irregular lines, in more 
complete centrifugal outline over the temple and brow; almost sym- 


NEW-GROWTHS. 


675 


metrically over the tip of the nose, and with odd indentations of con¬ 
tour in the dense integument immediately in front of the tragus of the 
ear. The vegetating forms are more common on the brow, scalp, and 
chin; the “ rodent-ulcer ” type, over the temples and cheeks. The 
more superficial varieties in any part of the face may slowly be con¬ 
verted into the deeper. The flattened, egg-sized disks of infiltration 
are more common on the cheeks and chin. 

The devastation produced by malignant cancer is nowhere more con¬ 
spicuous than in the face. Cartilage, bone, muscle, and entire organs 
melt before its ravages with astounding readiness. Within a period 
of two years a circumscribed flat epitheliomatous infiltration, limited for 
mauy months to one cheek, may spread to the point of destroying the 
ear, eye, and inferior maxilla of one side of the face, opening into the 
larynx and oesophagus, and not producing fatal result until the jugular 
vein of the same side is opened by ulceration. 

Cancer of the Lower Lip, far more common in men than in 
women on account of the tobacco-habits of the former, may arise 
either as a minute lobule or as a circumscribed thickening on or near 
the vermilion border, usually of one side, or as a linear, narrow, and 
shallow excoriation, often protected by a thin crust, extending well 
along the mucous edge of the lower lip that is in contact with the 
upper when the two are lightly approximated. Later, the lip may be 
the seat of a defined tumor, small nut- to egg-sized, that may deeply 
involve the entire thickness of the lip, encroach upon the chin, loosen 
the teeth, destroy the gums, larynx, pharynx, tongue, and maxilla, 
and eventually produce one of the formidable and remediless chasms 
of the lower part of the face already described. 

Cancer of the Genital Organs is submitted to the surgeon more 
frequently than to the dermatologist. The glans penis, the clitoris, 
and the prepuce are occasionally the seat of a warty variety; but the 
scrotum, labia, thighs, mons veneris, and abdominal walls, as well as 
the parts first named, may be involved in the superficial or the deep 
form of cancer. In persons of cleanly habits the superficial variety 
of epithelioma may persist in the genital region as indolent and innoc¬ 
uous as upon the face; but where filth is permitted to accumulate 
about the part (lochial, menstrual, catarrhal secretions; pus, urine, feces, 
etc.) the spread may relatively be rapid. The ulcer is then deep, seated 
upon an indurated and very tender base, and has the steep, punched 
edge and hemorrhagic floor of the rodent ulcer. Ulceration may, later, 
open the rectum, vagina, corpora cavernosa, perineum, and deep peri¬ 
neal fascia, resulting in vast destruction that proves fatal by exhaustion 
of the forces of the aged patient. 

Cancer of the Extremities, particularly of the back of the 
hand, is at first usually papillomatous, or of the flat, superficial form. It 
may appear upon the left hand of right-handed patients. Its progress 
is indolent, and wheu properly treated is much less liable to grave 
ulceration than epitheliomata in other situations. In special regions, 


676 


DISEASES OF THE SKIN. 


especially on the lower extremity where the force of gravity generally 
aggravates any ulcerative process, there may result caries, necrosis, 
fistules, loss of phalanges, etc. 

Cancer of the Mucous Surfaces may be primary or be second¬ 
ary in origin. The mucous lining of the oral and nasal cavities, of the 
vagina, the rectum, and the balano-preputial sac may thus be involved, 
either by extension of the disease from the neighboring cutaneous sur¬ 
face or by primary involvement of the mucous tissue. The most 
important, by reason of statistical frequency, is cancer of the tongue 
and buccal membrane, often having its origin in the leucoplasic stria- 
tions, plaques, or thickenings, known as “ smokers’ patches,” ichthy¬ 
osis linguae, psoriasis linguae, etc. A pin-head- to pea- or bean-sized 
superficial excoriation is usually the first lesion to which attention is 
attracted, reddish in color, granulating, tender, and not often very 
painful; or the beginning is a shallow fissure at the edge or on the tip of 
the tongue or on the mucous face of the lower lip, its long axis com¬ 
monly at right-angles to that of the organ upon which it forms. 
Beneath with more or less rapidity (as a rule slowly) a dense induration 
occurs, lancinating pains dart from the affected region toward the ear or 
along the jaw, the submaxillary and other glands become tumid and ten¬ 
der, deglutition painful, and in severe cases well-nigh impossible; or 
from the nasal membrane the disease extends toward the palate, phar¬ 
ynx, or larynx, ulceration, when it occurs, opening up a vast chasm 
which represents all these cavities. In the vagina and the rectum a 
cancerous change may begin with merely a thickening of the surface of 
the mucous membrane leading in the course of time to a superficial and 
later to a deep ulcerative process; or, as in cutaneous epithelioma, 
the papillary form may be represented in vegetations, cauliflower¬ 
shaped, filiform, or simply warty and mammillated, that eventually 
degenerate, and furnish the most formidable of destructive results. 

Paget’s Disease of the Nipple an d Areola (Eczematoid 
Epitheliomatosis of the Nipple; Malignant Papillary Dermatitis; 
Cutaneous Psorospermosis) was first described in 1874, by Paget, 1 
and has since attracted the special attention of a number of English, 
French, and American observers, including Thin, Duhring, Malassez, 
Darier, Wickham, and others. 

At the onset the disease suggests an eczematous involvement of the 
areola of the nipple, usually of one breast only, in women between 
forty and sixty years of age. According to Besnier and Doyon, the 
earliest change is without question a choking of the lacunae of the 
nipple with corneous cells, and this either without the operation of any 
known cause or as a consequence of a localized eczema, a galactorrhea, 
or other irritant. When early recognized the surface is intensely red 
and granulating, exuding quite copiously a clear viscid secretion, and 
producing subjective sensations of heat and burning, with intense or 


1 St. Bartholomew’s Hospital Reports, 1874, p. 87. See also the paragraphs devoted to this subject 
under the title of Eczema. 


NEW-GROWTHS. 


677 


with moderate itching. The definition is distinct, the tissue is in¬ 
durated, and the tenderness and pain are usually well marked and 
distressing. A marked feature of the disease is the circumscribed 
infiltration of the skin and subcutaneous tissue which on palpation 
suggests a large sized coin or button let into the substance of the areola 
and surrounding parts. 

AVhen the disease has progressed to this point a cancerous infiltra¬ 
tion of the breast is usually recognized, at least after its removal, 
though even with great care it may not always be possible to distin¬ 
guish it before ablation of the gland. Crocker, however, holds to the 
belief that the disease of the nipple may endure for years without 
resulting retraction and development of scirrhus of the breast. The 
French recognize three stages, that in which the disease is limited, 
respectively, to the nipple, the areola, and the breast, the later, of 
course, succeeding but not replacing the earlier. In all cases there is 
no attempt at repair; and when abandoned to its course the ultimate 
result, after five to eight or more years, is a profound ulceration with 
destructive effects most noticeable in the region of primary invasion, 
the entire breast having become cancerous. Cases of Paget’s disease 
affecting other parts of the body have been reported. In such cases 
the process is identical with that of superficial discoid epithelioma 
described on a preceding page. 

Pathology. Darier and AVickham, in a series of interesting papers 
published during 1889 and 1890, attempted to show that this disorder 
was to be included in a list of morbid processes which they desired to 
include under the title of “ Psorospermosis,” a group of affections of 
parasitic origin. These parasites were psorosperm-like bodies, coccidice 
in different stages of development, infiltrating the epidermis and all 
its prolongations. These coccidise, of the order of protozoa, multi¬ 
plying by dehiscence and subsequent diffusion in the tissues, became 
centres about which the epithelial masses clustered. The coccidise 
were roundish or oval in shape, 0.03 in length, double contoured after 
section of their encompassing capsule. 

But later investigations have shown that the so-called u psoro- 
sperms” are in fact simple alterations of epithelium that may be recog¬ 
nized in other affections as well as in Paget’s disease of the nipple. 
Sections of tissue in any case of well-marked malignant papillary 
dermatitis indicate with tolerable clearness the epitheliomatous char¬ 
acter of the process. There is a definite limit between the healthy 
and the morbid tissue; the rete-pegs, extended downward, fix their 
claw-like prolongations into the deeper structures; there is lymphoid 
cell-infiltration; epithelial nests; perivascular infiltration; squeezing, 
and in parts obliteration of papillse; loss of the superficial epiderm, 
when ulceration or erosion occurs; and, as pointed out above, choking 
of the lactiferous ducts with corneous cells. It is, in fact, by these 
ducts that the malignant process extends from nipple to gland, and 
this renders it in all cases a matter of extreme doubt whether the pro¬ 
cess is actually limited to the nipple and areola, or, when this choking 
has occurred, whether the gland is not already secondarily invaded. 

Diagnosis. There are few cases where the raw and exuding sur- 


678 


DISEASES OF THE SKIN. 


face can be mistaken for an eczema. The latter, when occurring upon 
the surface of the breast and of the nipple, is far more common during 
earlier periods of womanhood than after the fortieth year, chiefly 
among those giving the breast to sucklings. Eczema is never, under 
any circumstances, capable of producing in this region the character¬ 
istic button- or coin-sized induration beneath the deep-red, raw, gran¬ 
ulating surface of the cancerous infiltration. 

The treatment of Paget’s disease should always have in view the 
possibility of cancerous involvement of the gland that usually occurs, 
though a number of cases are on record when relief by other than 
radical measures was secured. Caustics should never be employed; 
all irritants are to be avoided. Soothing applications, as in corre¬ 
sponding states of eczema, the pastes, zinc and calamin lotions, diach¬ 
ylon and other soothing salves, are indicated and often prove service¬ 
able. The employment of parasiticides will hardly meet with favor, 
now that the psorospermosis theory of the disease is u menaced with 
death,” as Brocq declares. Mercurial lotions followed by powders of 
aristol, or hydronaphtol (1:100), and a weak ointment of pyrogallol 
or of iodoform are also extolled. Complete erasion of the morbid 
tissue may be successful, but ablation of the entire breast is demanded 
in most of the typically developed cases. 

The prognosis is not always grave. Cases are reported as relieved 
by local measures, which are always worth a judicious trial; but it 
must always be borne in mind that ineffectual measures may permit 
the involvement of the breast, eventually calling for ablation of the 
entire gland. 

Etiology of Epithelioma. The essential causes of cancer are un¬ 
known, though there can be no question that mechanical, chemical, and 
other local irritations are often immediate excitants of its pathological 
processes in the predisposed skin. In this way the excoriations, warts, 
nevi, and other lesions named above, though not in themselves can¬ 
cerous, may become the original sites of the disease. In this way, 
too, the irritation produced upon the lips of the smoker by his pipe or 
tobacco; the local disorder about the inuer canthus of the eye resulting 
from occlusion of the lachrymal ducts; the frequent teasing by caustic 
or other substances of the wart on an old man’s hand; and other 
agencies disturbing the balance between waste and repair, aided at 
times by senile atrophic changes, may result in the development of an 
epithelioma. The possibility of the transmission of cancer by heredity 
has almost ceased to obtain credence in the light of modern pathology, 
yet Broca reports sixteen deaths from cancer in one family, and Fried- 
erich a congenital epithelioma in the child of a cancerous woman. 

The disease is eminently one of advanced life, being most frequent 
after the fortieth year, and a pathological curiosity in childhood. 
Kaposi reports one case at the tenth year. Only about 30 per cent, 
of all cases occur in women, a fact possibly explained by the relative 
infrequency of the action of local irritants in those who are not sub¬ 
jected to the exposures incidental to the trades and severe occupations 
of life. 


NEW-GROWTHS. 


679 


These figures, however, relate only to cancer of the skin, since, 
when cases of cancer of the breast and of the uterus are included, the 
proportion of the sexes affected is almost exactly reversed. 

In favor of the local origin of cutaneous epithelioma is the clinical 
fact of the excellent general health of most patients in the earliest 
stages of the malady; while those affected with syphilis and tubercu¬ 
losis are usually exempt. The theory that carcinoma is due to a specific 
parasite and is, therefore, infectious and contagious, is gaining ground. 
No parasite has yet been demonstrated, since the protozoa-like bodies 
which Darier and others described in cancer-cells have been pretty 
clearly demonstrated to be forms of cell-degeneration. 


Fig. 88. 



Patholooy of Epithelioma. All epitheliomata have their origin in 
pre-existing epithelium. The old idea that they originated from con¬ 
nective tissue has been disproved. The essential feature of all forms 
of epithelioma is the proliferation of epithelium and its growth into 
the deeper tissues where it is not normally found and where its pres¬ 
ence causes secondary inflammatory changes. Two pathological types 
of epithelioma are of interest to the dermatologist, the lobulated and 

^In^th e'iobulated form the interpapillary processes of the rete send 
down prolongations which subdivide and branch in all directions, the 
branches intercommunicating and giving off buds and processes w ic i 
may form new centres of growth. The origin of the growtli may bc 
traced to the interpapillary processes or to the epithelium of the seba¬ 
ceous glands, coil-glands, or liair-folhcles, but more frequently the 
source cannot be determined absolutely, since the band connecting the 
growth with its starting-point may have been destroyed by ulceration, 
or on the contrary, the glands and follicles may be involved second¬ 
arily Attempts have been made to classify epitheliomata according to 
the structure from which each originates, but there seems to be no good 
ground either clinical or pathological for such distinction. The branc 1 - 
ing processes form variously shaped lobules, and the cells composing 
them 3 assume, as the result of pressure, many shapes. Lsually, how- 


680 


DISEASES OF THE SKIN. 


ever, the outer layer of a lobule is a row of cylindrical cells within 
which are cuboidal prickle-cells which toward the centre are under¬ 
going a more or less complete cornification, the centre itself being com¬ 
posed of horny stratified cells. Thus the structure of a lobule from 
without inward corresponds closely with that of the normal epidermis 
from within outward! Sometimes the prickle-cells within the lobules 
show no tendency to cornification. In places the lobules are com¬ 
pressed into globular masses having concentric layers like an onion. 
These bodies are the epithelial “nests,” “ globes,” or “pearls.” 
The centre of such nests not infrequently shows colloid, fatty, or gran¬ 
ular changes. In rare instances calcification of the lobule occurs. 

The connective tissue of the part into which the growth has pene¬ 
trated surrounds and supports the lobules and may remain almost nor¬ 
mal, or be thickened, infiltrated with round cells, or its fibres may be 
mixed with epithelial cells; it contains blood-vessels, none of which 
penetrate the lobules. In some cases the epithelial growth proves 
greatly irritating to the surrounding tissues, exciting in them marked 
inflammatory processes. Fordyce thinks the inflammation may be due 
in part to a pus-infection, and in one case, by using Gram’s method, 
he has demonstrated staphylococci in the inflamed tissue. 

In the tubular variety of epithelioma the epithelial elements form 
freely anastomosing, cylindrical processes which extend vertically, 
horizontally, aud at various angles through the cutis and often into the 
subcutaneous tissue. The cells are smaller than in the lobular variety 
and do not, as a rule, undergo cornification or form “ nests.” The 
outer row of cells may be cylindrical and stain deeply, and as the tubu¬ 
lar processes may assume shapes highly suggestive of gland-formation, 
this variety of epithelioma is supposed by some observers always to 
originate in the epithelium of a coil- or sebaceous gland. Largely 
owing to the ease and rapidity with which the starting-point or connect¬ 
ing-band may be destroyed by ulceration, it is often impossible to 
demonstrate the origin of the processes, but the investigations of 
Darier, Pollitzer, Fordyce, and others, have led to the belief that the 
growth originates rarely in the sebaceous glands, but frequently in the 
rete or in the epithelium of the coil-glands and hair-follicles. 

Tubular epitlieliomata are, as a rule, less malignant and less rapid 
in their course than are those of the lobular type. Transitional forms 
are seen, however, which tend to show that the shape and mode of de¬ 
velopment of the processes depend as much upon the accident of location 
and surrounding tissue as upon the character of the epithelium from 
which they originate. Rodent ulcer—which some authors describe 
under a separate head—is pathologically a tubular epithelioma. 

Diagnosis. Epithelioma is to be distinguished from lupus vulgaris 
approximately, by the age of the patient, the latter disease rarely 
appearing after the thirty-fifth year where there is no scar or a history 
of its earlier existence. Lupus is, at an earlier period of its career, 
more diffuse than epithelioma; its elementary forms are more dis¬ 
tinctly groups of individual lesions than a homogeneous aggregation; 
its ulcers are more often bordered by outlying non-ulcerative papules, 
furnish a more puriform discharge, and, most distinctive of all, are 


NEW-GROWTHS. 


681 


never walled about by the firm, densely indurated, often everted lip of 
the epitheliomatous ulcer, opening out often to a sound peripheral 
integument. The peculiar and often characteristic odor of the cancer- 
discharge is absent in lupus. 

From syphilis, epithelioma is to be distinguished: first, by the age 
of the patient, syphilis being decidedly a disease of early and middle 
life; second, by the far greater relative rapidity of the syphilitic pro¬ 
cess, exception being always made of tertiary gummatous ulcers upon 
the lower extremities persisting for years when there is both lack of 
internal treatment and of local support; third, by the history of the dis¬ 
ease in each particular case; and, fourth, by the characteristic syphilitic 
features always present in infected individuals, including multiplicity 
of lesions, typical cicatrices, contour of ulcers (that of epithelioma is 
less often either reniform, horseshoe-shaped, or crescentic), character 
of discharge, and general absence of pain. A very important point 
to note is a marked tendency to reparative cicatrization in old syphilitic 
ulcers, partly due to the exhaustion of the infective poison, partly to 
the influence of an insufficient but yet modifying treatment. This 
tendency is exceedingly rare in epithelioma, which is often, while syph¬ 
ilis is rarely, a malignant disease. 

Epithelioma of the genitals is not to be confounded with chancre, 
gumma, or syphilitic tubercles of that region. The peculiarities of 
the consequent adenopathy in each case; the lancinating pains of can¬ 
cer; its much more prolonged duration; and its occurrence in an aged 
subject, with the general history of the case, will usually point to the 
truth. 

Sarcoma is characterized by its far more rapid evolution, the tumors 
often attaining their maximum of development in the course of a few 
months; by its occurrence by predilection in earlier life; by its inapti¬ 
tude for ulcerative degeneration; and by its marked tendency to mul¬ 
tiplication in contiguous or in distant portions of the body. 

The warts, nevi, excoriations, and seborrheic lesions, from which 
epitheliomata often take their origin, cannot be determined as having 
such a tendency before the cancer has attained some development. 
Every such persistent and long-irritated lesion on the person of a male 
subject of advanced years should be regarded with a degree of suspicion. 

Treatment. No internal treatment for cancer of the skin is known 
to exert the slightest influence upon the growth. 

The topical treatment of epithelioma is by excision, erasion, or de¬ 
struction of the growth. The first is performed by surgical ablation 
with the bistoury, after which one of the plastic operations may be 
required for either the complete covering of the wound, or the relief 
of the resulting deformity. The second is applicable only to the less 
formidable growths, and is performed by the aid of the dermal curette. 
The third is effected by the use of caustics. The removal of smaller 
epitheliomata, of the face especially, by the aid of the dermal curette, 
should generally be followed by the thorough application of caustics, 
especially nitrate of silver in crayon. 

Destruction of smaller cancerous tumors of the skin may be per¬ 
formed by the aid of caustics, of which caustic potash, in stick or in 


682 


DISEASES OF THE SKIN. 


solution, is, perhaps, the most valuable, as its destructive action may 
be controlled by the topical employment of acids, and it is followed by 
less pain than some of the other chemical agents. Other caustic sub¬ 
stances employed for a similar purpose are: chlorid of zinc, Vienna 
paste, nitrate of silver, arsenical paste, resorcin, pyoktanin, fuchsin, and 
pyrogallol. The latter is highly recommended by Kaposi, not only 
because its application is unproductive of pain, but also because it does 
not attack sound tissue. It is used in an ointment of 10 per cent, 
strength. All such pastes and ointments should be spread upon cloths, 
and be applied for from three to six days. Opiates may be required, 
in the case of several of these agents, to relieve the consequent pain. 

Among the formulae used for caustic purposes are the following : 

&.—Creosoti, ^ss; 16 

Acid, arsenios., gr. iv; 266 

Opii pulv., gr. ij; 133 M. 

Sig.—For employment upon circumscribed surfaces. [Kaposi.] 

Marsden’s paste, also employed as a caustic, is made by combining 
equal parts of gum arabic and arsenious acid with water sufficient to 
make a softish paste. It is preferred by Robinson 1 to others, and is 
applied on rubber plaster. 

Cosmos paste, as modified by Hebra, is prepared as follows: 


fit-—Acid arsenios , 

Hydrarg. sulphuret. rub., 
Unguent, aq. ros., 

Sig.—Arsenical paste. 


g r - vj ; 


40 


M. 


The method of its application is as follows: the paste is spread over 
a thin sheet of lint to the thickness of a knife-blade, and lint is then 
cut to a shape and size corresponding with that of the tumor or ulcer 
to be destroyed. After its close apposition with the surface to be 
attacked, it should be covered with gutta-percha, or other impermeable 
tissue, and a compress laid over the whole. In twenty-four hours the 
dressing is removed, the parts washed clean, and the same application 
renewed. By the third or the fourth day the destruction of the can¬ 
cerous growth is usually complete, and the parts are ready for an 
emollient poultice, which should be applied for the three or four days 
during which the separation of the sloughs occurs. The simple ulcer 
left is to be treated on general principles. The danger of arsenical 
poisoning is here reduced to a minimum; the treatment being very 
effectual where patients consent to the delay as to time and to the 
very severe pain which it occasions. It is highly praised by Atkinson 2 
in an admirable lecture on epithelioma, delivered by him in the Uni¬ 
versity of Maryland. 

The thermo- and galvano-cautery may also be ofteu advantageouslv 
used for the destruction of the growths. The advantages of the thermo¬ 
cautery are: the transitory character of the induced pain; the coal-like 
dressing left upon the attacked surface; and the elegance of the result- 

1 Some Considerations on the Treatment of Cutaneous Malignant Epitheliomata. Internat. 
Journal of Surgery, 1892. [A valuable paper.] 

2 Reprint, in Chicago Medical Journ. and Exam., Aug. 1883, p. 188, from the Virginia Medical 
Monthly. 




NEW-GROWTHS. 


683 


mg scar. Both measures find their highest value when employed 
after effectual incision or erasion. 

Whatever method be employed, thoroughness is essential in attack¬ 
ing all portions of the new-growth; and it is well to encroach somewhat 
upon the unaffected contiguous structure. The subsequent dressings 
should be made with simple or carbolated unguents, to which one of 
the salts of morphin may be added in case of continuous pain. The 
eschar usually separates in the course of a few days, leaving a simple 
granulating wound which may soundly cicatrize, and the epithelioma be 
thus radically relieved. In other cases the disease reappears in the 
ulcer or cicatrix, or, by recurrence of cancerous nodules, in the pre¬ 
viously sound integument. Even after these recurrences, prompt 
destruction of the new-growth may finally be successful. 

But little confidence is placed upon any external treatment which 
does not effect the complete destruction of the neoplasm. Yet there 
are those who highly esteem some of the procedures which are less 
radical in their aim, and which it is proper to mention here. 

Some circumscribed and relatively small growths disappear under 
a borated hot-water treatment. By this method, the neoplasm is 
sponged with hot borated water for from fifteen to twenty minutes 
every three hours of the day, and oftener if possible, for three weeks 
in succession. The water is as hot as can be tolerated, and is applied 
by the aid of a bit of sponge mounted on a probang. During the 
course of the application water in a state of ebullition is added in 
small quantities to that in which the sponge is dipped from minute 
to minute, thus keeping the temperature at the highest tolerated point. 
Immediately after each application the part is thoroughly dried, and 
then either anointed with a bland unguent or completely covered with 
boric acid, aristol, europhen, or iodoform in powder. When such appli¬ 
cations are of service, the good effect will usually be noted in a week. 
The ulcer changes its aspect in color, edges, and floor; and the pain, 
if any have existed, is greatly relieved. Granulations of a healthy 
type appear, and the lips of the sore contract. Yon-ulcerated lesions 
shrink in volume, and otherwise change in feature. This system of 

parboiling” has the advantage of not precluding the ultimate em¬ 
ployment of radical measures. The largest epithelioma completely 
relieved by this method was of the type of the “ rodent ulcer,” on the 
temple of a male patient seveuty-two years of age. It had the size of 
that of a section of a small hen’s egg. The resulting cicatrization was 
satisfactory in all respects. Needless to say, the method will often 

fail. 1-1 

Leveque, 1 Vidal, 2 Bergeron, 3 Euthyboule, 4 and others claim large 

success in the treatment of epithelioma by chlorate of potash. Locally, 
the part is frequently touched with a saturated solution of the salt in 
glycerin and warm water, after which a simple ointment dressing is 
applied. Vidal administers also the same drug internally, in doses of 
IJ drachms (6.) in syrup and water before meals. It is possible mat 
any remedial effect obtained from such measures should be attributed to 


1 Glasgow Medical Journal, 1881. 
3 Acad, de Med., Paris, 1873. 


2 Loc. cit. 

* TMse de Paris, 1877 


684 


DISEASES OF THE SKIN. 


the fomentations employed. Latterly, benzole and pyoktanin-blue 
have been reported as valuable topical applications to small-sized 
epitheliomata. 

Injections of solutions containing copper-sulphate, iodiu, alcohol, 
acetic acid, nitrate of silver, chlorid of sodium, and hydrochloric acid 
have been practised, it is claimed, with some success; certainly at times 
with fatal results. This method is unquestionably inferior to others 
described above. 

Prognosis. In general, the prognosis of cutaneous cancer is grave. 
The relative degree of gravity will, of course, largely be proportioned 
to the variety, form, size, career, and complications of the growth in 
each case. The variety in which only u pearls’’ form in the skin is 
the most benign of all, as the lesions are usually isolated, and may, 
when unirritated, undergo spontaneous exfoliation. In other cases, 
the disorder for from fifteen to twenty years seems to make no progress 
of any sort. The malignity of a cancerous growth is always propor¬ 
tioned to the quantity of epithelium contained in its alveoli as com¬ 
pared with the connective tissue present; the more abundant the latter, 
the more favorable the prognosis. Naturally, also, the deeper and 
the more destructive the growth, the fewer are the chances of ultimate 
recovery. Excessive pain and adenopathy are unfavorable symptoms 
in any case. Koch 1 gives some interesting statistics of the results of 
operations, at the Erlangen Clinic, for the removal of epithelioma of 
the lower lip, in one hundred and thirty-one patients exhibiting 
primary lesions. One hundred and fifteen of these were for the time 
“ cured;” four had speedy relapse; and three were, at the date of 
writing, living and suffering from recurrence of the disease. The 
prognosis was thus absolutely favorable in but tw T enty-eight cases. 


Cancer of the Connective Tissue. 

This is rare as a primary cutaneous manifestation, but appears gen¬ 
erally as secondary to a cancerous involvement of other organs, as of 
the female breast. It is termed also Scirrhous, Hard, Fibrous, or 
Lenticular Cancer. It occurs either upon the skin covering a 
breast which has previously been transformed into a cancerous mass, 
or as a cutaneous relapsing lesion after the extirpation of the latter. 
Its symptoms are pea- to bean-sized, densely firm, shining nodules, 
varying in color; or a more or less diffuse infiltration of the skin of 
similar characteristic hardness, associated often wth hyperemia of a 
purplish-red shade. 

Cancer en Cuirasse. When the cancerous infiltration is wfidely 
diffused and densely indurated, involving a large portion of the in¬ 
tegument of the thorax, the condition is termed by the French cancer 
en cuirasse (Fig. 89), a title first given by Velpeau. In these cases 
the condition is striking in its peculiarities, and in the highest degree 


1 Centralblatt f. Cbirurg., 1881, No. 40. 


NEW-GROWTHS. 


685 


serious. The integument of a large portion of the chest, usually more 
in front, but also behind, and even a part of the anterior abdominal 
wall, is converted into a dense leathery envelope, often so compress¬ 
ing the chest-wall as seriously to impede respiration. The edges of 
the infiltration are poorly defined save at the lines where tongue-like 
prolongations (languettes) of dull reddish hue indicate the advance of 
the scirrhous process over the skin. The lymphatic circulation is 
obstructed, the glands enlarge, and, what is almost pathognomonic of 
the disorder, the upper extremity, usually of the side chiefly involved, 
becomes enormously swollen and oedematous. The nipple may or 
may not be retracted; the breasts, one or both, are firmly bound down 
to the chest-wall by the cuirass of dense skin, hard, smooth, or rough, 

Fig. 89. 



Cancer en cuirasse, chiefly involving the right side of the chest (from a painting in oil). 


shining, and either reddened in dull hues or of normal tint, here and 
there traversed by vessels, and breaking down into ulcerations, usually 
first about the nipple, but also elsewhere. The process is one of the 
more rapid of the scirrhous metamorphoses of the body, as a fatal 
result is usually reached in a few months, though years have in some 
cases elapsed before death resulted. One of the author’s, patients, an 
unmarried woman, with breasts in the virgin state, perished, in the 
course of a few months, the cancer having originated in the skin. The 
milium-like masses, as large as grains of wheat (conspicuously present 
in Morrow’s case, cited below), undergoing fatty degeneration in the 
centre and readily expressed like comedones, are not always present. 

An interesting case of widely disseminated lenticular cancer of the 






686 


DISEASES OF THE SKIN. 


skin (illustrated by an excellent portrait) described by Morrow, 1 
occurred in a healthy-looking woman as a secondary phenomenon after 
removal of primary cancer of the breast. 

The author has had several cases of this disorder under observation, 
two being made the subject of a paper, 2 with illustrations of the clinical 
appearances and morbid condition of the tissue. One of the patients 
was a man. Whether the nodules be, as to cutaneous manifestations, 
primary or secondary, the symptoms are generally the same. The 
lesions are closely set, shining, firm, reddish papules, infiltrations of a 
dull reddish hue, miliary and pigmented deposits, tubercles varying 
in size, subcutaneous nodules, and secondary results in the way of 
formidable ulcers, crusts, and fungous growths. 

The prognosis is serious. 

Pathologically, the several forms of carcinoma above described are 
epitheliomatous, since the fibrous stroma always contains, in the centre 
of narrow alveoli, a relatively small number of epithelial bodies. The 
growth is usually slow of development, but in the end is accompanied, 
as are other cancerous tumors, by adenopathy, pain, and ulcerative 
changes, which induce an inevitable cachexia. As with the other 
varieties, relapse after extirpation is common, and the prognosis is pro¬ 
portionately grave. 


Tuberose Carcinoma 

is a rare manifestation of the disease, occurring in the form of multiple, 
firm, peanut- or egg-sized, roundish nodules, which break down by 
ulcerative processes into deep losses of tissue. It is frequently accom¬ 
panied or followed by cancerous involvement of other organs. It 
occurs chiefly upon the face, hands, arms, and chest, though also upon 
other portions of the skin of persons of advanced years, either as a 
primary or a secondary cancerous manifestation. Guinard 3 reports a 
cancer of this variety, remarkable for the smallness of the existing 
nodules, which varied in size from that of a hempseed to that of a pea. 
They covered the entire thorax, the back, and the right arm; and 
had here and there broken down into ulcers. One of the latter was 
as large as the hand. 


Melanotic or Pigmented Carcinoma 

is that form in which both the epithelium and connective-tissue frame¬ 
work of the cancer are richly supplied with blood-vessels, and, prob¬ 
ably, as a consequence of transudations from the latter, with an abun¬ 
dance of pigment-granules in groups and clusters. These growths 
usually begin as hempseed- to pea-sized, single or numerous, soft or 
dense nodules, which may develop in time into tumors of considerable 

1 Journal of Cutaneous and Venereal Diseases, June, 1884, p. 1. 

2 American Journal of the Medical Sciences, March, 1882. 

3 Union Med., February 5,1881. 


NE W- GROW THS. 


687 


size, and which are stained in various shades from a grayish-brown or 
a slate-color to a dead black, the pigment being occasionally displayed 
irregularly in streaks or bands over the surface of the growth. They 
occur over any portion of the surface, often upon the extremities and 
the genitals, starting frequently from benign pigmentary lesions, such 
as nevi and moles. Anatomically, the pigment is found to be depos¬ 
ited both between the cells and in the protoplasm of the cells themselves. 

In a few instances the disease is limited to single melanotic growths 
of this character. The cancer is apt to develop into the papillary 
form, furnishing thus fungoid vegetations which have a noteworthy 
tendency to degenerate into ulcers. Often such verrucous masses are 
seen surrounded by grayish or blackish papules, or by a diffuse can¬ 
cerous infiltration of the integument; they also exhibit irregular pig¬ 
mentation of the surface. The disease is apt to appear in the viscera, in 
the form of disseminated cancerous nodules, each highly vascular, and 
exhibiting in varying quantity granules of pigment. The growth has 
usually a relatively rapid course and malignant career. Relapses are 
frequent, the amount of pigment usually increasing with each relapse. 

Benign Cystic Epithelioma (Hydradenome Eruptif, Cellulome 
Epithelial Eruptif). Jacquet, Darier, and Quinquaud have described 
under these respective titles a dermatosis occurring upon the neck, the 
chest, and the upper extremities, that is chiefly characterized by its 
indolent course and by the evolution of shot-like, reddish or rosy- 
reddish papules, somewhat firm and seated within the derma. They vary 
in size from that of a pin-head to that of a pea, and are oval in con¬ 
tour, their long axis usually directed in the line of the cutaneous folds. 

The observers named believe these papules to be benign epitheliom- 
ata developing as a result of the evolution of aberrant embryonal 
epithelium, originating often in the coil-glands. 


SARCOMA CUTIS. 

(Gr. oapf;, flesh.) 

Statistical frequency in America, 0 044. 

Sarcoma of the skin is characterized by the occurrence, either as primary or as sec¬ 
ondary developments, of single or multiple, pea- to egg-sized and larger, pigmented 
and non-pigmented, cutaneous and subcutaneous neoplasms having a marked inap¬ 
titude for ulceration but malignant in character, recurring after extirpation, and 
usually terminating fatally with involvement of the viscera. 

The term sarcoma , meaning a fleshy tumor, was originally employed 
by Virchow in the designation of this disease. Its anatomical features 
have carefully been studied since by Rindfleisch, Cornil and Ranvier, 
Babes, Heitzmann, and others. 

Cutaneous sarcoma is rare and obscure among cutaneous affections. 
Two groups are readily distinguished : 

(A) Primary Melanotic Sarcoma, or Melano-sarcoma. This 
is the more common form. It may develop from a pigmentary nevus 


688 


DISEASES OF THE SKIN. 


which has been irritated, or from any pigmented point upon the integ¬ 
ument, especially upon the dorsum of the hands and feet, the lower 
extremities, the genital region, and the face—oyer the cheek or near 
the orbit, where it may originate from the choroid coat of the eye. 

It may be of primary occurrence or may develop as a secondary 
deposit. The lesions are bean- to egg-sized, usually single or multiple, 
very firm or doughy, sessile or pedunculated, spheroid or lobulated; 
they vary in color from grayish-brown to deep black. The epidermis 
which covers them may be discolored, thinned, and intact, or be ulcer¬ 
ated. The color may be of any shade to an inky blackness. The 
nodules are often surrounded by blackish puncta which eventually 
develop into tubercles. The lesion or lesions may for a long time 
remain stationary, or they may rapidly be followed by generalization, 
as a result of local irritation, either by extension from a central point 
to adjacent tissue, or by transmission through the lymphatics to a dis¬ 
tance from the primary nodule. 

In a case lately observed, the left lower extremity of a middle-aged 
woman was studded with split-pea-sized to marble-sized, ink-black 
masses from the ankle to the middle of the thigh. The larger were 
always centres of groups of similar pin-head-sized black nodules. The 
skin of the region affected was swollen, inextensible, inelastic, and 
as firm as sole-leather. The disease had rapidly extended from the 
ankle upward in the course of a few months. 

Pathologically, tumors of this kind are found to exhibit the anatom¬ 
ical features of sarcoma in general, with pigment distributed both 
within and between the cellular elements of the tumor, and between 
the fasciculi of connective tissue in the framework. A sarcomatous 
growth is one of the most malignant and rapidly fatal of all neo¬ 
plasms. Therapy is unavailing; and the prognosis is grave indeed, 
a fatal result usually occurring with rapidity after the occurrence of 
generalization, and commonly with visceral complications by reason 
of secondary deposits. 

Melanotic Whitlow (Hutchinson) is described as a chronic ony¬ 
chia, displaying pigmented spots, suggesting nitrate-of-silver stains at 
the edge of the nail-fold, where eventually a fungous tumor forms with 
increase of pigment until the nail is exfoliated, and the process becomes 
generalized. 

(B) Primary Non-Melanotic Sarcoma. This occurs in both 
localized and generalized forms. 

The localized variety of primary non-melanotic sarcoma is quite rare, 
and is seen chiefly in women. As in other sarcomata, it is often first 
recognized at a poiut where a nevus or other warty growth has become 
irritated, but more often over the extremities. At such a point there 
forms a firm, dull-whitish nodule, having nearly the hue of the nor¬ 
mal skin, rarely vascularized, that may, after persistence without 
change for a variable period, break down by ulceration and become 
the seat of a fungous vegetation. Generalization of the process may 
result either spontaneously or from accidental complications. 


NEW-GROWTHS. 


689 


The disease, when affecting the skin in multiple lesions, is charac¬ 
terized by the appearance of several, usually at first isolated, pea- to 
nut-sized and larger, smooth, spherical, irregular, or lobulated, cuta¬ 
neous or subcutaneous tumors. They may or may not at first be 
attached to the epidermis above and to the deeper structure beneath, 
but they eventually contract such adhesions. Between them the skin 
may not be involved. In uncomplicated cases at this period, the con¬ 
spicuous features of these lesions are: (a) their whitish color, due to 
their envelopment in an unaltered epidermis ; (b) the history of a rela¬ 
tively rapid development, as distinguished from fibromata, epitheliom- 
ata, gummata, and lupous tubercles; (c) the speedily declared systemic 
results of the growth. 

Later, the skin between the lesions becomes swollen, infiltrated, pain¬ 
ful; and, even before the tubercles desquamate, enormous tumefaction 
and redness of an erysipelatous type may affect the internodular tissue. 
In this way an entire limb, only one portion of which is the seat of 
tubercular growth, may attain an elepliantiasic size, ulcerate at one or 
more points, and pour out an offensive secretion as a consequence of 
ulceration of the inflamed integument. 

In the course of time, weeks not years, the nodules or tumors of 
sarcoma coalesce, degenerate by ulceration, and participate in the pro¬ 
cess going on in the inflamed and 
excoriated skin where they are im¬ 
planted . Death results either from 
exhaustion, intercurrent fever, or 
sarcomatous involvement of one 
or of several viscera. By the same 
process the skin-lesions may be 
the product of metastasis from the 
lymphatic glands or the viscera. 


Fig. 90. 


The disease occurs in this form 
over the chest, the extremities, 
and the genitalia, though all parts 
of the skin have been invaded. 

The patient from whom were re¬ 
moved the tumors, whose micro¬ 
scopical features are represented in 
the accompanying illustration (Fig. 

90), was a woman in middle life. 

The disease is both rapid in 
course and malignant in type. In 
a total of more than fifty thousand cases of diseases of the skin reported 
to the American Dermatological Association, only sixteen were sarco¬ 
matous, the actual percentage being 0.027. 



Sarcoma: spindle-cells visible in sections of 
cutaneous nodule removed from a sarcomatous 
patient. (About X 300.) 


Generalized Primary Non-Melanotic Sarcoma of the Skin 
(“ Idiopathic Multiple Pigment Sarcoma ” of Kaposi, Tanturri, De 
Amicis, Wigglesworth, Hallopeau, and others) owes its coloring to 
cutaneous hemorrhages. It occurs chiefly in male subjects (from forty 
to sixty years of age) who have been laborers, whose hands and feet 

44 


690 


DISEASES OF THE SKIN. 


become tlie seat of an oedema, accompanied by pruritus and other sub¬ 
jective sensations. Later, brownish, bluish-red, or dark purplish 
spots appear, out of which develop pin-head- to pea-sized nodules, 
gradually increasing in volume, discrete, tender, and often grouped. 
They may be the seat of lancinating and radiating pains. As they 
multiply, a lardaceous infiltration progressively involves the depth of 
the integument, until an elephantiasic condition is produced, a hand, 
a foot, or an entire limb becoming of cartilaginous hardness, bluish 
in tint, and covered with a smooth, mammillated, squamous, or rugous 
envelope, which may be also the site of tumors of considerable size. 
These tumors are fewer in number and smaller in volume as they 
spread from the distal to the proximal parts of the limb. They may 
be sessile, pedunculated, and grouped, but they are always of a deep 
bluish or violaceous tint. 

These growths may remain for a long time stationary, or they may 
be entirely resolved, the patient apparently securing complete recovery. 
Very rarely they ulcerate or exhibit slight erosions. At times they 
are covered with or surrounded by telangiectases, or by tissue exhibit- 
iug infiltration of blood. When the mucous membranes are involved, 
points, patches, disks, or infiltrations of a dusky-reddish, or a bluish 
shade appear on the inner side of the gums, the lips, the tonsils, or 
over the palate; and there is visceral involvement with lymphatic 
and vascular changes. The usual signs of physical exhaustion ensue, 
with fever, dysenteric symptoms, hemoptysis, and marasmus. The 
disease may last only from three to five years, but a duration of four¬ 
teen years has been recorded. Post-mortem, tumors have usually been 
recognized in the viscera. Only a very few infantile cases have been 
recorded. 

Remarkable instances of complete recovery from this affection are 
multiplying. A patient with the hands completely relieved was shown 
at the International Dermatological Congress in London, in the year 
1896, Kaposi himself having verified the diagnosis. A patient rapidly 
recovering from the same disorder is at present under the author’s 
observation. 

Recurrent Fibroid of the Skin (Hutchinson), beginning usually 
in the lower extremities, and tending to slow extension, rapid and per¬ 
sistent recurrence, and tendency to ulcerate and form fungous tumors, 
with ultimate marasmus, is set down by Crocker as a rare form of 
spindle-celled sarcoma. 

The etiology of sarcoma is unknown. According to Babes, sarcomata 
are frequently congenital, and are not rarely found in early youth upon 
the eyelids, the extremities, and the genitalia. 

Pathologically , according to the same author, sarcomata are new- 
formations of embryonal tissue with abundant proliferation of vascular 
elements and vessels. As to the former, numerous rudiments of ves¬ 
sels multiply without developing into complete vascular channels, often 
making eventual connection with pre-existing vessels. In these there 
may be a complete or an incomplete production of blood. In other 


NEW-GROWTHS. 


691 


cases, the parietal portions of young blood- and lymph-vessels prolif¬ 
erate abundantly in an embryonal formation of fasciculi and alveoli, 
either choking the lumen of the original vessel, or transforming it into 
vacuoles, cups, and spaces. 

All tumors of this character are abundantly supplied with cells, the 
proportion of which to the stroma is markedly in excess. They never 
resemble embryonal and granulation tissues. The cells may be spindle- 
shaped, spheroidal, branched, with one or many nuclei, and either large 
or small. The fibrillar basement-substance, according to Delafield 
and Prudden, 1 may be present in such small quantity as entirely to 
escape superficial observation; or be so abundant as to suggest the 
appearance of a fibroma. This substance may be closely inwoven 
with the cells in such bundles, or may exhibit wide and open meshes 
presenting the appearance of alveoli. The cells are in intimate rela¬ 
tion, and are often continuous with the basement-substance. Both 
cells and substance are in the same close relation with the vascular 
elements described above, upon which Babes relies so largely for iden¬ 
tification of the nature of the growth. 

Virchow described originally five varieties of sarcoma: round-celled, 
net-celled, giant-celled, and melanotic. In spindle-celled sarcoma the 
cells may be large or small, and may vary so greatly in proportion to 
the stroma as to furnish the subvariety of fibro-sarcoma, in which the 
fibrous tissue abounds between the cells. These (‘ells may be encapsu¬ 
lating or be infiltrating. The mass of the tumor is then constituted 
of a decussating feltwork of spindle-shaped, nucleated, protoplasmic 
bodies. 

Round-celled sarcoma is constituted of globular, protoplasmic ele¬ 
ments closely packed together, and separated by a very narrow layer 
of cement-substance, traversed by delicate prolongations of the living 
matter which uninterruptedly counect the elements. The vascular 
supply is scanty. There are two forms of this growth found in the 
skin : (a) that with relatively large protoplasmic bodies and large 
nuclei—large round-celled sarcoma; (6) that with relatively small 
homogeneous lumps of living matter—small round-celled sarcoma or 
u lympho-sarcoma.” The last-named varieties are, as a rule, more 
rapid in growth and more malignant in career than the former. 

In the u alveolar sarcoma,” of Billroth, there is a delicate con¬ 
nective-tissue framework, containing attached globular or pyriform 
bodies. Heitzmann recognized this form once in the skin of the left 
groin. 

The compound varieties of the disease, myxo- and fibro-sarcoma, are 
occasionally seen in the skin. The formation of secondary tumors is 
explained, according to Heitzmann, by the transmission of minute 
particles of the neoplasm to capillaries of a fine lumen, presumably 
through the blood-vessels, as the lymph-ganglia are rarely involved. 

The diagnosis rests upon microscopical examination of the new- 
growth in every case. Sarcoma should not be confounded with fibroma, 
epithelioma, gumma, or lupous nodules. 


i Handbook of Pathological Anatomy and Histology, New York, 1885. 


692 


DISEASES OF THE SKIN. 


Treatment is highly unsatisfactory. Surgical ablation of these tumors 
is apt to be followed by their speedy return. 

Koebner’s injections of arsenic (usually Fowler’s solution, 2 to 4 
drops in one to two parts of distilled water, repeated every second day 
for months, with gradual increase of the dose) seem to have proved 
successful in two cases. Arsenic, potash, and ergot, internally, and 
salol, camphorated naphtol, aristol, and bismuth subnitrate locally, 
have secured only transitory results. 

The prognosis is exceedingly unfavorable, a fatal issue occurring in 
most cases. 


MYCOSIS FUNGOIDES. 

(Gr. fJ-VKrjg, a mushroom.) 

(Granuloma Fungoides, Granuloma Sarcomatodes, Inflam¬ 
matory Fungoid Neoplasm, Eczema Tuberculatum, Fi¬ 
broma Fungoides, Lymphodermia Perniciosa, Sarcoma- 
tosis Generalis. Fr. y Lymphadenie Cutan^e.) 


Mycosis fungoides is an infective disease, characterized by various cutaneous phe¬ 
nomena which finally result in the production of one or of several well-defined, 
firm, reddish tumors, probably due to the presence of specific micro-organisms. 

This disease was first described in 1814 by Alibert, as <( Pian fon- 
goide.” Its symptoms resemble that affection in an obscure degree, 
though not in any way related to it. 

The disease is rare, but so many cases have been carefully observed 
and fully reported that dermatologists are now familiar with all the 
symptoms of the disorder. An attempt has been made to distinguish 
between two forms. There is, however, but one; and this may or 
may not be preceded by what has been called the u pre-mycosic stage.” 

Symptoms. The so-called “ pre-mycosic stage” is characterized by 
the occurrence of a series of dermatoses of different types, erythema¬ 
tous, urticarial, psoriasiform, usually in patches with and without def¬ 
inition, circumscribed and vivid in hue ; or diffuse and dull-reddish ; 
palm-sized, coin-sized, or punctate. These patches are probably symp¬ 
tomatic, for the mycosic plaques do not necessarily spring from areas 
of the skin thus involved, though there is a possibility that this may 
be the case at times. The so-called “ pre-mycosic stage ” may last for 
months or for years; it may wholly be absent. Its absence may not 
increase the portentous character of the malady. 

The earliest symptoms of the disease proper are circumscribed infil¬ 
trations, button-sized to palm-sized and larger, often intensely pruritic, 
rosy-reddish or having a highly characteristic pinkish-red hue, that 
exhibit a warty surface, often scratched, fissured, and as a consequence 
hemorrhagic, or here and there stained with blood-crusts, particularly 
in the more advanced stages of the disease (lichenoid plaques, of Bazin). 
These infiltrations may disappear, leaving very peculiar circumscribed 
vitiliginous plaques where they existed; or the tumors described below 
may develop from them; or they may be in full development, furnish- 


NE W-GROW TIIS. 


693 


ing no tumors, when the latter are growing with mushroom-like rapidity 
from other parts of the body, more particularly over the face; or, 
lastly, defined circumscribed areas, destitute of pigment, resembling 
leucodermatous patches, may occur in the skin where there has been 
no warty plaque. 

In a variable period of time the characteristic tumors of the disease 
appear upon the face, scalp, chest, and other portions of the body 
(Fig. 91). They are bean- to palm-sized; whitish; pinkish, or pale- 
reddish in hue ; well-rounded, and distinctly circumscribed. Often 
they are like flat buttons, movable with the skin. They may then 
disappear by absorption while others appear; they may degenerate by 
erosion leading to superficial ulceration; or they may melt down into 


Fig. 91. 



Mycosis fungoides (from an oil painting made at the bedside). 


deep losses of tissue by ulceration. Coincidently the lymphatic glands 
may enlarge, and this adenopathy, as in case of the tumors, may sub¬ 
side to be replaced later by similar involvement of the same or of other 
glands. 

When the tumors have attained maturity and before involution has 
begun, their appearance, especially upon the face, is characteristic. 
They are smooth, moderately firm, sausage-like in shape, often lobu- 
lated, of a peculiar reddish hue, and produce when numerous, a lepra- 
like deformity, closing the eyes by their size or weight, producing the 
leonine brow and the elephantiasic ear. In the author’s case illustrated 
in the appended cut, 1 the body of the patient was extensively covered 
with tumors of all sizes, resembling those seen on the face. 

The general condition of the patient at first seems unaltered; later, 


1 Edinburgh Medical Journal, 1883-1884, xxix. p. 592. 


694 


DISEASES OF THE SKIN. 


when the tumors ulcerate, exhaustion occurs and the victim usually 
dies, as in other cutaneous disorders of similar gravity, as a result of 
febrile processes, or of an intercurrent diarrhea, or of cachexia. When 
the tumors are many and ulceration extensive, the appearance of the 
patient is repulsive iu the extreme, the exhalations from the body are in 
the highest degree fetid, and the difficulty of securing antisepsis, hygienic 
care, and comfort for the wretched sufferer is well-nigh insurmountable. 

The fully developed tumors occur upon all parts of the body, upon 
the palmar and plantar surfaces, the arms and forearms, the thighs and 
legs, the face, and the back. Often they are in various degrees pig¬ 
mented, showing then purplish, brownish, or even black colors. They 
are usually painful, and may or may not be tender. They sometimes, 
after disappearing, leave atrophic or pigmented depressions as relics of 
their career. They are said to ulcerate rarely. In one patient ulcera¬ 
tion attacked some of the tumors, leaving crateriform excavations in 
their centres, but this was an exception to the rule, the larger number 
present preserving their shape in death. In a few cases vegetations 
appeared upon the summit, smeared with a thin and very offensive 
secretion. 

When the tumor is single, and apparently uncomplicated by involve¬ 
ment of deeper organs, extirpation is usually followed by recurrence, 
either in the scar or vicinity, with added malignancy. 

On the backs of the hands the lesions may appear no larger than 
small marbles, with infiltration of the skin lying between the nodules, 
producing thus the appearance of a small, well-rounded cushion. The 
epidermis of such an oedematous hand usually exfoliates in silvery- 
white or grayish scales, more or less adherent. The feet and legs may 
exhibit a similar appearance. 

The disease has been studied abroad by Hebra, Kaposi, Geber, 
Alibert, Fox, Kobner, Auspitz, and others; in America by Duhring, 
Piffard, Wigglesworth, Tilden, 1 and the author. 

Etiology. The disease is fortunately rare. Tilden collected the 
records of thirty cases of the disease and of sixteen deaths. Twenty- 
three patients were males and seven females; more than half the 
number were over forty years of age; in only one-fourth of the num¬ 
ber had the disease developed before I he twentieth year of life. There 
can be little question to-day as to its infectious character. It is prob¬ 
ably produced by a specific micro-organism. 

Pathology. Under the microscope sections of tumors removed 
from patients affected with the disease exhibit infiltration of the 
corium and subcutaneous tissue with small round cells arranged in 
circular or in irregular groups, enclosed in a narrow stroma of fiue 
connective-tissue fibres, with often a centrally situated blood-vessel. 
The epidermis, at first spared, is afterward involved by ulceration. 
According to Gannett, who examined sections in Tilden’s case, the cells 
corresponded, morphologically, with lymph-corpuscles. The nature 
of the process is yet in dispute, as recent investigations have added little 
of definite value. By some mycosis fungoides is considered a lympho- 


1 Consult Dr. Tilden’s Monograph, Boston Medical and Surgical Journal, October 22, 1885. 


NEW-GROWTHS. 


695 


sarcoma, by others a lymphadenoma, but the majority of observers 
incline to the view that it is a granuloma. 

Micro-organisms have been recognized in mycosis fungoides by 
Rindfleisch, Auspitz, 1 and others. An exhaustive report on the sub¬ 
ject (illustrated by a photograph) has been made by Auspitz’s collabora¬ 
tors, Hochsinger and Schitf; 2 and Professor Firket, 3 of the University 
of Li£ge, reported a case in which micrococci were recognized. Payne, 
Kobner, Donitz, Lassar, and other later investigators have failed to 
find a specific parasite, and think the micrococci reported by Rind- 
fleisch and others were due to secondary infection. Post-mortem 
examination has rarely shown visceral involvement. 

The diagnosis of mycosis fungoides cannot be made with certainty 
before the characteristic tumors have been developed. After that the 
peculiar shape, reddish color, situation, and relative rapidity of the 
growth point to the nature of the disease. 

From lupus vulgaris, with which mycosis fungoides may be con¬ 
founded in view of the age of the patient, it may be recognized by its 
relative rapidity of evolution, its failure to ulcerate at an early stage, 
and the absence of cicatrices in cases where there has been no operati ve 
interference. 

Svphilis is to be distinguished by its history, its multiformity, its 
ulcerative type, and its amenability to specific treatment. Lepra does 
indeed, when occurring in its rare and acute forms, suggest mycosis 
fungoides of the face. But the presence or history of hyperesthetic 
or anesthetic symptoms, of bullous or macular lesions, and the absence 
of deforming mutilations in advanced periods, will usually point to the 
nature of the disease. The tubercles of lepra are smaller than the 
tumors of mycosis fungoides; more bronzed and less fleshy in color; 
and of far less general distribution than in several cases of the last- 
mentioned disease on record. 

The treatment is unsatisfactory. With the knowledge now possessed 
as to the nature of the disorder, the bichlorid of mercury would cer¬ 
tainly be indicated in the local management of the disease. 

The comfort of the patient is to be secured by all measures, includ¬ 
ing anodynes in an advanced stage of the disease, and his strength 
should be supported bv a generous diet and tonic regimen. Arsenic 
in full doses and by hypodermatic injection has been of apparent 
service in some cases. Locally- ichthyol, oleate of bismuth, and many 
other preparations have been of service in allaying the symptoms and 
retarding the progress of the disease. When the affection is generalized 
tepid baths are productive of great comfort; the use.of boric acid, 
resorcin, aristol, carbolic acid, or some similar agent is indicated by 
the fetor arising from the person. The body should be anointed with 
a bland unguent after each bath. Extirpation of the tumors is proper 
when such a course will add to the comfort of the patient. 

The prognosis is unfavorable. The patient may survive from a few 
months only to a maximum of fifteen years, the average being from 
two to four years. 


696 


DISEASES OF THE SKIN. 


CLASS VII. 

NEUROSES. 

HYPERESTHESIA. 

(Gr. virep, above; aloft rjoic, sensibility.) 

This is a condition characterized by exaggerated sensibility unat¬ 
tended by structural changes in the skin. It may be idiopathic or 
symptomatic, general or partial, unilateral or bilateral, and may also 
vary greatly in the degree of abnormal subjective sensation by which 
alone it is declared. In mild cases there is unusual sensitiveness to 
contact with foreign bodies, such as the clothing; in other cases, the dis¬ 
tress occasioned by even the passage of a feather over the skin-surface 
is almost intolerable. The symptomatic variety of the malady is most 
common, occurring as one of the several manifestations of hysteria, 
tetanus, and other nervous disorders, including certain forms of motor 
paralysis where sensation has been retained, though in a perverted 
condition. 

The disease is properly classed with the neuroses of the skin, with 
respect to the etiology and pathology of which much remains to be 
investigated. Its chief manifestations are the production of itching 
and pain. 

The former is much more frequently experienced in the skin than 
the latter; and is an almost constant symptom of active cutaneous 
hyperemia and exudation. The paresthesias (in which sensations of 
heat, formication, tickling, dripping or pouring of liquids of various 
temperatures are experienced) are more often associated with extra- 
cutaneous affections. 

Pain, solely and simply limited to the skin, is, in fact, a neuralgia 
of a nerve having a cutaneous distribution. 


[A] Pruritus. 

(Lat. prurire, to itch.) 

Statistical frequency in America, 2.12. 

Pruritus is a functional disorder of the skin, characterized by the sensation of itch¬ 
ing in a part or over the whole body, and unaccompanied by objective symptoms 
of disease, save those produced by attempts to relieve the local distress. 

Symptoms. Pruritus is to be distinguished not only from prurigo, a 
rare disease of the skin already described, but also from the symp¬ 
tomatic sensation of itching which is occasioned by a number of cuta¬ 
neous disorders, such as eczema, scabies, and those produced by pediculi. 

Hebra was first to recognize the independent character of the disease 
here considered; but it is to be regretted that he did not give to it a 


NEUROSES. 


697 


name distinct from that which is also applied to a symptom common 
to several maladies of the skin. 

Pruritus is characterized by a sensation of itching not produced orig¬ 
inally by cutaneous lesions. It may be general or be partial. In 
either form it begins usually by a tickling, pricking, crawling, or 
itching sensation in the skin, which solicits the sufferer to rub, press, 
scratch, or otherwise irritate the affected integument. It usually occurs 
by accesses in the day or the night, much more often the latter, occa¬ 
sionally both; and these accesses manifestly occur under the immediate 
stimulus of some internal or external cause. Thus, moral emotions, 
a cool draught of air, the warmth perceived when in bed, the pressure 
of clothing, and often the substances applied externally with a view to 
the relief of the pruritus, suffice to determine a crisis. However firmly 
the sufferer may determine to avoid injury to the person, in well-marked 
cases the impulse to scratch becomes well-nigh irresistible, and, in the 
highest degree, tormenting. Prom the milder, the patient will thus fre¬ 
quently be teased to inflict the severer injuries upon the skin. Brushes, 
combs, coarse cloths, and even metal instruments will be employed in 
exaggerated cases for the purpose of assuaging temporarily the local 
distress. 

The objective cutaneous symptoms which may be presented are all 
secondary, and invariably result from self-inflicted injury. In some 
cases they do not appear, the statements of the patient being the sole 
basis for a recognition of the disease. This absence may be the con¬ 
sequence of unwonted self-control, or of the mildness of the malady, or 
of the transitory character of the lesions produced. Thus, the skin 
may be reddened during a nocturnal paroxysm under the manipulation 
of the sufferer, and the transitory hyperemia disappear in the daytime 
when the skin is submitted for inspection. Not rarely, however, the 
integument resents the treatment to which it is subjected, by displaying 
wheals, hyperemic blotches, reddened papules, excorial ions, charac¬ 
teristic “ scratch-lines,” and the minute blood-crusts which indicate 
that the papillary layer of the derma has been reached and slightly 
torn. As these causes are among those recognized for eczema and 
dermatitis, it is not surprising to note that such disorders of the skin 
may in this way be originated, and may still further add to the subjec¬ 
tive distress. Skins which have for years been the seat of a persistent 
pruritus leading to traumatisms of the epidermis, are always deeply 
pigmented. 

The localized forms of pruritus, albeit the abnormal sensation is in 
them limited to certain regions of the body, may occasion fully as much 
distress as those in which a larger part of the integument is affected. 
They are of more frequent occurrence than the generalized forms. 
Pruritus of the anus, of the scrotum, of the vulva, of the vagina, of 
the scalp, of the nose, of the mouth, of the axillae, are all localized 
forms of the disease, two or more of which may coexist or may develop 
in succession. 

Pruritus Narium is a frequent symptom of irritation of the Schnei¬ 
derian membrane. It is thus a common precursory or an attendant 


698 


DISEASES OF THE SKIN. 


phenomenon of rose- or hay-asthma; and in some individuals announces 
the systemic effect after ingestion of opium and its alkaloids. It occurs 
also in children as a result of pediculosis of the scalp. It may result, 
further, from the irritation awakened by intestinal parasites. 

Pruritus Genitalium is often an exceedingly severe and distress¬ 
ing affection. As the parts in question are apt to be rubbed and 
scratched in efforts to secure relief of the itching sensation, there are 
produced in early youth and extreme age orgastic effects and pollutions, 
whose moral effects are degrading. The scrotum, the labia majora 
and minora, the penis, the clitoris, and the adjacent cutaneous and 
mucous surfaces may be the seat of the pruritus. Search should always 
be made, in these cases, for ascarides of the rectum or of the vagina, 
for saccharine and albuminuric urine, and uterine or ovarian affections. 
A perverted sexual hygiene may lie at the root of these disorders. In 
severe cases the violence with which the parts are attacked suggests 
freuzy on the part of the patient, who at times is never content until 
the scrotum or other parts are bathed in blood. The thickening, ero¬ 
sions, and excoriations of the regions attacked are conspicuous features 
of the disease. 

Pruritus Ani. This is a disorder of adults of both sexes, and it 
may coexist with pruritus of the genital region. There is usually noc¬ 
turnal exacerbation. The anus may become infundibuliform from 
induration; its mucous surface excoriated; its cutaneous borders 
seamed, puckered, eroded, and fissured. It is often complicated with, 
because the origin of, an eczema whose lesions reach upward over the 
coccyx or forward to the genital region over the perineum. Hemor¬ 
rhoids, ascarides, chronic prostatitis, rectal impaction, proctitis, unnat¬ 
ural vices, gout, alcoholism, albuminuria, or diabetes may each be re¬ 
sponsible for its occurrence. In all exaggerated forms of pruritus 
cutaneus the general health perceptibly fails. Whether the prolonged 
insomnia arises from nocturnal exacerbations to which there are but few 
exceptions; or from the perversion of nutrition incident to the continu¬ 
ous teasing of the nervous system; or yet from the hypochondriacal state 
into which some patients are plunged by their sufferings, such an issue 
is often to be expected. It is, in fact, a complication which may 
merit, as much as the disease itself, the attention of the physician. 

Pruritus Palmas et Plants is a rare form of this disorder, in 
which the itching is limited to the palms and soles. It may complicate 
gout, malaria, hyperidrosis, and asthma. 

Etiology of Pruritus. The causes of pruritus are numerous, and 
the necessity for the discovery of the particular cause in each patient 
often makes the largest demands upon the practitioner. The disease 
may occur at all periods of life aud in both sexes, but its exaggerated 
forms are peculiar to middle life and advanced years (Pruritus Se¬ 
nilis). It is frequently a reflex symptom of one of several internal 
disorders. Among the latter may be named malarial affections, 


NEUROSES. 


699 


tuberculosis, carcinoma of the viscera, disorders of the liver or kid¬ 
neys (especially jaundice, Bright’s disease, and diabetes), and disturb¬ 
ances of the alimentary canal, including those due to intestinal worms, 
hemorrhoids, and dietetic or medicinal ingesta. It may be associated 
with almost every one of the functional, and not a few of the organic, 
disorders of the uterus and ovaries. The same may be said of its 
dependence upon the genito-urinary diseases of the male sex, including 
stone in the bladder, stricture of the urethra, disorders of the testes 
and epididymis, and perverted sexual hygiene. 

Lastly, moral emotions of a depressing character play an impor¬ 
tant part in the etiology of pruritus. Mental distress, occasioned by 
bereavement, separation from relatives, misfortune of all sorts, and 
anxieties as to the future, often find physical expression in the disease. 

Pathology of Pruritus. The disease is essentially a functional dis¬ 
order of the nerves of sensation supplied to the skin, and of itself is 
incapable of producing objective symptoms. This fact can, in some 
cases, be clinically demonstrated, as the seat of the pruritus, even 
though exhibiting artificially produced lesions, will, when protected 
from all external injury, speedily regain its normal appearance, the 
pruritus no less continuing. It is probable, though not certain, that 
the nerves also in this disease undergo no structural change, but merely 
convey to the periphery a perverted sensation which is often reflected 
from some centric point of disturbance. 

Diagnosis of Pruritus. The recognition of general pruritus is 
usually not difficult, though the secondary results of the disease are 
apt to be less marked than its early phenomena. The complaint of the 
patient, the absence of cutaneous disease sufficient to explain the symp¬ 
toms, and especially the discovery of such a sufficient cause in some 
visceral or systemic disorder, are all significant. 

One of the most constant features of general pruritus is visible only 
when the clothing of the patient is entirely removed. It then becomes 
evident to the eye that the affected regions are, in the order of frequency, 
those most accessible to the hands. The posterior are much less 
involved than the anterior body-surfaces. The small of the back and 
interscapular regions are usually untouched. The tibial regions of the 
legs and the skin of the forearms suffer more than the calves and the 
upper arms. The lower belly and inner faces of the thighs are pun¬ 
ished more severely than the breast and outer faces of the thighs and 
the hips. The clavicular regions are more excoriated than the back 
of the neck. There is no more precise evidence than this as to the 
pruritic character of any cutaneous affection, and it is one too often 
ignored by the practitioner who prescribes under these circumstances 
for a “disease of the blood.” 

It must be admitted, however, that when the disease is localized 
and complicated, as it frequently is, by an eczema or a dermatitis, 
doubt may arise. Attention should then be paid to the history of the 
disorder, which may reveal the fact that the pruritus preceded for some 
time the cutaneous symptoms, and may disclose even more. Intelli¬ 
gent patients will often assure the physician of the real nature of the 
malady, by voluntarily remarking that the skin symptoms disappear 


700 


DISEASES OF THE SKIN. 


upon the region which is not scratched, though the pruritus continues. 
In all cases the operation of exterior agencies should carefully be 
eliminated. 

Prurigo, with its intiltrated skin, its primary papules, and its severe 
itching, beginning in early infancy and commonly persisting through 
life, can scarcely be confounded with pruritus cutaneus. 

Treatment of Pruritus . The degree of success to be obtained in the 
treatment of pruritus cutaneus is largely proportioned to the skill with 
which the cause of the disease is recognized and remedied. Taking 
into consideration the number of systemic and visceral disorders which 
may in different cases be responsible for the skin symptoms, it is clear 
that an exhaustive study of the mental and physical history of each 
patient will be essential at the outset of treatment. The cause once 
recognized, the treatment should be directed to the special disorder 
discovered; and this largely requires the skill of the general practi¬ 
tioner. The gastro-intestinal tract, the kidneys, the liver, the bladder, 
the uterus, the prostate gland, the rectum, and indeed any one of the 
viscera, may require therapeutic management. For the frequent gas¬ 
tric disorders, the alkalies and alkaline waters, with occasional cathar¬ 
tics and strict regulation of the diet, are often useful. Attention should 
particularly be directed to any medication to which the patient may 
have been subjected with a view to therapeutic effect, and which may 
have aggravated the complaint. The mineral acids, chalybeates, pep¬ 
sin, lactopeptin, quinin, strychnin, phosphorus, arsenic, or atropin 
may be indicated in individual cases and be productive of favorable 
results. 

The substances which have been employed topically for the relief 
of pruritus cutaneus are almost without number, a fact warranting 
the conclusion that each occasionally fails to afford the desired re¬ 
lief. This fact is corroborated with every wide clinical experience; 
that preparation, moreover, which is at one time of the highest value, 
will disappoint at another period in the history of a single case. 
Attempts to secure relief by such topical applications should, however, 
always be made, and will often be followed by gratifying results. 

First in order of value are lotions and baths of water, hot, warm, 
or cold, or alternately hot and cold, and medicated by the addition of 
sodic bicarbonate or biborate, potassic carbonate or sulphuret, varying 
in strength from 1 ounce (32.) of the last-named to 6 ounces (192.) 
of the first-named substance, in thirty gallons of water. Gelatin 
or bran may often with advantage be added to these baths, as sug¬ 
gested in the chapter on General Therapeutics. Alcoholic, ethereal, 
camphorated, and carbolated lotions are to be regarded as of equal 
value. Duhriug specially recommends solutions of carbolic acid, in 
the strength of from 5 to 20 grains (0.33-1.33) to the ounce (32.) of 
water, to which J drachm ( 2 ) of glycerin has been added. R 0 I 16 
simply employs boric acid, 1 drachm (4.) to the pint (512.). 

Van Harlingen adds the antipruritic effect of potash as follows: 


R.—Acid, carbolici, 
Potassse fus., 
Aq. dest., 


3j; 

3ss; 
Oss; 


4 

2 

256 


M. 



NEUBOSES. 


701 


Baths and lotions of the above character usually procure merely 
temporary relief, and the treatment in the interval of their application 
demands the wearing of soft linen or other unirritating material next 
the skin, and the free use of a dusting-powder. Pure starch-powder 
is here less useful than are powders compounded with oxid of zinc 
and bismuth, as in the “Anderson powder.” Gorecki 1 mingles the 
starch with perfectly pure boric acid. 

R. W. Taylor, of New York, in a valuable paper, 2 gives the fol¬ 
lowing formulae: 


R.—Potass, sulphuret., 

3iijl 

12 j 


Camphorse spts., 

fSss; 

16 


Glycerin., 

; 

32 


Aq. font, 

q. s. ad f 3 vj ; 

192 

M. 

Sig.—For external use as 
strip of lint. 

a lotion, to be applied by the medium of a 

saturated 

R.—Camphor, spts. 

fgss; 

16 


Boracis, 

3*j; 

8 


Glycerin., 

f |ij; 

64 


Aq. fluv., 

3Y1; 

1921 

M. 

Sig—To be well shaken and applied externally. 




Morphin, in the strength of 1 grain (0.066) to the ounce (32.), may 
be added to this and other lotions. 

Chloral-camphor, a pungent, syrupy liquid obtained, as suggested 
by Bulkley, by triturating an equal amount of the two substances in 
fine powder, is an antipruritic remedy of value in certain cases if 
applied in a salve containing 1 drachm (4.) to the ounce(32.) of salve, 
and is comparable in its action to phenol-camphor, described in the 
chapter on General Therapeutics. 

Other lotions may be made to contain corrosive sublimate, J grain 
(0.016) to the ounce (32.); dilute hydrocyanic acid, or menthol, 1 drachm 
(4.) to the half-pint (256.); Goulard’s extract, 1 drachm (4.) to the 
pint (512.); chloroform, sulphur, alum, oil of peppermint, dilute nitric, 
acetic, or salicylic acid, tannin, or zinc sulphate in due proportions. 
Often aqua calcis, medicated with calomel, zinc oxid, bismuth, or cala- 
min, answers well, and, if tolerated at all, the addition of linseed oil, 

4 ounces (128.) to the pint (512.), with 1 drachm (4.) of one of the 
inert substances named, flavored with rosemary or bergamot, will aid 
in relieving the local distress. 

Ointments and fatty substances in general are usually not well toler¬ 
ated in cutaneous pruritus. Occasionally, however, they are of more 
value than lotions, and may be made to contain one or more of the 
substances named above, such as carbolic acid, from 5 to 15 grains 
(0.33-1.) to the ounce (32.); subnitrate of bismuth, 1 scruple (1.33) to 
the ounce (32.); chloral-camphor, 5 minims (0.33) to the ounce (32.); 
and calomel or ammoniated mercury (especially in pruritus ani) from 

5 to 10 grains (0.33-0.66) to the ounce (32.), of cold cream, petroleum 
ointment, or lard. 

Tarry substances may not well be tolerated in the disease, and they 
are, as a rule, when the skin is sound, objectionable as liable to irritate. 


1 Le Praticien, October 3,1881, p. 473. 

i On the Various Forms of Pruritus Cutaneus, and Treatment. 


Arch, of Clin. Surg., 1877. 



702 


DISEASES OF THE SKIN . 


Duhring, however, speaks well of the liquor carbonis detergens, in 
the strength of 1 drachm (4.) to 2 ounces (64.) of water. This alco¬ 
holic solution of coal-tar has been for some time in the market of large 
cities. The liquor picis alkalinus may similarly be employed. 

Special attention has been directed by many writers to the treatment 
of the local forms of pruritus, the principles of which treatment have 
been in the main described above. 

For pruritus of the vulva, Wiltshire' recommends decoctions of 
almond-meal, marshmallow, slippery-elm, and rice; and in case of 
failure of the latter, an infusion of tobacco 2 ounces (64.) to the pint 
(512.). Vaginal injections of hot water, and tampons or cocoa-butter 
suppositories medicated with opium, belladonna, or carbolic acid, are 
also available. 

Many of the medicaments named above are also useful in pruritus 
of the anogenital region. The application of very hot water is of 
decided service. Exception should be made here to the rule with regard 
to the exclusion of tars generally from the treatment of pruritus, as in 
the distressing itching of the scrotum and the anus especially they are 
often essential. The tincture of tar, oil of cade, and oil of white 
birch will here often be needed. Pencilling any existing fissures 
with compound tincture of benzoin or nitrate of silver is serviceable. 
The scrotum when attacked usually requires the use of a suspender, 
or suspensory bag, lined with soft lint or with borated cotton, which 
may also be incorporated with a dusting-powder, wetted with a lotion 
or smeared with an unguent. 

Simon successfully employed pilocarpin in cutaneous pruritus, both 
internally and by hypodermatic injection. For the latter, the muriate 
of pilocarpin is used in doses of ^ grain (0.011). The same author 
administered with good results a syrup of jaborandi, made in the pro¬ 
portion of three parts of the leaves of the plant to fifteen of water, and 
eighteen of dissolved white sugar, of which two tablespoonfuls are taken 
at a dose. 

In Europe, the favorite local application for relief of pruritus is a 
lotion containing tar in some form. Usually from 5 to 10 per cent, 
of ^glycerin is employed in a spirit lotion. Salicylic acid is often sub¬ 
stituted for it, e.g .; 


R.—Acid, salicylic., 

5 

Spts. vin. rectif., 

i ij ; 

Aq. dest., 

S iij ; 

Sig.—Lotion. 


Schwimmer recommends: 


R.—Alumin. hydrat., 

3j ss ; 

Glycerin., \ 


01. oliv., J 

aa ^ v j 

Ungt. moll., 



Sig.—Ointment. 


4 

64 

96 


M. 


6 

20 

40 


M. 


Thin lotions of starch-water or of oatmeal-gruel (iced or cooled 
in hot weather), to each pint of which 1 drachm or more of zinc 


1 British Medical Journal, March 5,1881, p. 328. 




NEUROSES . 


703 


ox id or subnitrate of bismuth may be added, are often of immediate 
value. 

Iodoform, oleate and muriate of coca'in, the latter in from 2 to 4 
per cent, solutions; 1 ounce (32.) of the fluid extract of coca, to 2 
or 4 of water; and linseed oil (especially for pruritus ani), are also 
recommended. 

Jullien recommends in pruritus of the vulva: 

R.—Zinc, oxid , 3 yj; 24 

Acid, salicylic., gr. xv; 1 

Glycerin , 3 vj; 24| M. 

Sig.—Apply as required. 


Cheron, in pruritus of the vulva attending the menopause, has suc¬ 
cessfully used: 


R.—Veratrise, 
Axung., 


gr. nj ; 

Jj; 


1200 

32 M. 


He also administers in pill-form grain of veratria rubbed up 
with licorice. 

Squibb’s formula is: 


R.—Acid, tannic., 9j ; 

Glycerin , j 4& j 

Spts. vin. rectif., J 0 ’ 

Aq. dest., ad f^iv; 

Sig.—Apply morning and evening on a rag. 


1|33 

16! 

128' M. 


Lastly, it should not be forgotten that many cases of intractable 
pruritus are best managed when the attention of the patient is diverted 
from the malady by the distraction incident to travel, aided by change 
of scene and climate. 

There are strong reasons for refusing to employ in pruritic disorders 
preparations containing cocain, cannabis indica, conium, and others of 
similar character intended to relieve the subjective sensations by inter¬ 
nal medication. Many well-nigh incurable cases of the “ cocain- 
habit ” have been begotten by treatment of this sort when the patient, 
often a nervous woman with an intolerable pruritus vulvse, is in a 
condition peculiarly susceptible to the action of remedies of this class. 
The latter should always be regarded as the last resort of the practi¬ 
tioner, and a confession of his own weakness in not discovering the 
special cause effective in the case with which he is for the time con¬ 
fronted. 

Prognosis of Pruritus. Pruritus senilis is usually an intractable 
disorder, and, when dependent upon senile alteration of the cutaneous 
tissues, is incurable. For all other forms of the disease a prognosis 
should be formulated with reserve. Under the influence of systematic 
and appropriate treatment the happiest results are often obtained. 
Other cases, especially those associated with hypochondriasis, may bid 
defiance to all medicinal measures. Relapse of the local forms of the 
malady, especially of that of the anogenital region, is sufficiently 
common. In many of these patients the treatment serves merely to 
palliate the disorder, which recurs with every renewal of the cause. 


704 


DISEASES OF THE SKIN. 


Pruritus Hiemalis [Prurigo Hyemalis, “ Frost-itch, ” 
Winter Prurigo]. Under the first title Duhring 1 described a harsh 
and pruritic condition of the skin, essentially unattended by structural 
alteration, invading all surfaces of the body, but chiefly the inner 
faces of the thighs, the calves of the legs, and the neighborhood of 
the joints of the lower extremities, usually occurring in the autumn, 
and continuing until the following spring. It possesses many features 
in common with the forms of pruritus already described, including 
variability in the subjective sensations awakened, nocturnal exacerba¬ 
tion, and the absence of primary eruption. The secondary results are 
also similar, being sequels of self-inflicted injury in the form of rough¬ 
ness, perifollicular redness and papulation, torn and fractured hairs, 
excoriations, blood-crusts, and, in severe cases, an induced dermatitis. 
It, however, abates in severity with a rise of atmospheric tempera¬ 
ture, though there is occasionally noted persistence of the distress 
after such weather-changes. The affection, moreover, is one which 
occurs in persons otherwise enjoying perfect health, in those of every 
social grade, irrespective of the character of the clothing worn and of the 
habitual use or the neglect of the bath. It is, without question, a disease 
of northern climates, more particularly of those where the variations 
of temperature between the extremes of the summer and of the winter 
range between 100° and 125° F. The careful description by Duhring 
presents a picture (with an accuracy verified by clinical observation) 
which justifies the recognition of the disease as a form of cutaneous 
pruritus. Its treatment is that detailed above, the author named 
laying stress upon emollient unguents, glycerin in the form of lotion 
or ointment, and alkalin baths. The dusting-powders, when em¬ 
ployed after the tepid bath, have proved more serviceable than any 
fat-containing substance. 

Prairie Itch. This is a popular term applied largely in the Wes¬ 
tern, Northwestern, and Southern States of America to a cutaneous 
affection productive of itching sensations. It is supposed to be the 
disorder popularly described also as the “ Texas Mange,” a Ohio 
Scratches,” “ Swamp Itch,” “ Lumberman’s Itch,” etc. A par¬ 
asitic origin has been claimed for it by several observers, who also 
insist upon its contagious character and its curability by parasiticides. 

Personal experience has led to the conviction that these terms are 
loosely applied to a group of cutaneous symptoms of diverse origin. 
The most frequent by far is a pruritus, of the kind described above 
as pruritus hiemalis, occurring in the autumn, winter, or spring of the 
year, and aggravated by the coarse and cheaply dyed woollen under¬ 
garments of the poor and hard-working inhabitants of the lumber- 
camps, mining-districts, etc. With these causes in full operation, 
there is often aggravation after swallowing drugs for relief of the 
pruritus based upon the idea of “ purifying the blood.” 

With these pruritic cases occur those of undoubted scabies, for the 

1 Phila. Medical Times, January 10,1874. See also, a later but independent observation by Mr. 
Hutchinson: Lectures on Clinical Surgery, 1878, vol. i, pt. 1, p. 100, and British Medical Journal. 
1875, ii. p. 773. 


NEUROSES. 


705 


study of which the reader is referred to the chapter devoted to that sub¬ 
ject. The proportion between the purely pruritic and purely parasitic 
cases of this class cannot definitely be determined. It probably differs 
in different places and seasons, the proportion of cases of scabies increas¬ 
ing in the lumber-camps when they are reinforced by newly arrived 
immigrants infested with acari. It decreases to probably not more 
than from 1 to 2 per cent, of all skin diseases in the interior villages 
and towns of the West and Northwest where there has been no immi¬ 
gration for some length of time, and where, after the first onset of 
sharply cold weather in the autumn, a large part of the inhabitants 
suffer from pruritic sensations in various degrees. 

A review of the somewhat scanty literature on this subject 1 suggests 
the conclusion that the disorder popularly designated as “ prairie itch,” 
etc., is far more rare in Europe than in America. It is possible that 
the situation of those parts of the United States where this group of 
skin affections seems to prevail (at a great distance from proximity to 
the seashore, and still further separated from the Gulf-stream) may 
play an important part in the extraordinary sensitiveness of the skin 
to climatic changes. Certain it is that a great number of these affec¬ 
tions are entirely relieved by removal to a suitable climate, more par¬ 
ticularly to one of the Eastern, Southern, or extreme Western States. 

Treatment. The therapy of this affection is that of pruritus, already 
described, save where a parasite is recognized as the efficient cause, as 
in cases of scabies. 

The prognosis is favorable, though the disease is at times intractable, 
persisting or recurring with repeated thermometric variations until the 
warm season is at hand. 


[B] Dermatalgia. 

In this morbid state the integument becomes the seat of painful 
sensations, which may or may not be associated with a hyperesthetic 
condition. This disorder is much more frequently symptomatic than 
idiopathic, and partial rather than general, being in the larger number 
of cases a local expression of some disease of the nervous centres 
or tracts. It is observed usually in middle life, and in women 
more than in men. Its symptoms vary in severity and in character. 
The pain is differently described as comparable to that produced by 
friction, incision, penetration, contusion, or burning of the integument, 
as also to the passage over the part of streams of very hot or of cold 
water, or the electric current. With this there is commonly associated 
an undue sensitiveness to contact with foreign bodies. The skin pre¬ 
sents no objective signs of disease. The disordered sensations may be 
limited to the scalp, the region of the spine, or the palmar and plantar 
surfaces. In the latter situation it is often significant of some 
obscurely developed systemic disease, such as syphilis, rheumatism, 


i See two papers by Ihe author, entitled “ On the Affections of the Skin, Induced by Tempera- 
ture Variations in Cold Weather .” Chicago Med. Journ. and Examiner, March, 1885, and Feb- 
ruarv 1886 Obersteiner: Wien. med. Wochenschrift. 1884, No. 16. Brodie: Peninsul. Journ. of 
Medicine, 1853-54, vol. i. p. 506. Jones : Kansas City Medical Index, 1886, with views of several 
Western Physicians. Clark: Medical Age, 1886. Payne : British Medical Journal, May 3,1887. 

45 


706 


DISEASES OF THE SKIN. 


or locomotor ataxia. In a middle-aged woman a persistent derma- 
talgia of the interscapular region was associated with confirmed gastric 
dyspepsia. In other cases the disorder is dependent upon disturbance 
of the uterine function. It is occasionally observed as one of the 
rare signals of the occurrence of the menopause. 

It is to be noted that the severe dermatalgia associated with disor¬ 
ders of the uterus in women is occasionally succeeded by a cutaneous 
lesion. In a middle-aged dysmenorrheic patient under observation, 
a pea-sized hemorrhagic bulla appeared over the forehead after several 
weeks of frontal suffering. Buck, 1 also, reports dermatalgia of the 
brow and wrists in a young woman who had frequently miscarried, 
followed by recurrent formation of a vesicle which accomplished its 
career of rupture, crusting, and erosion, in a stadium of from five to 
seven days. 

Diagnosis. The disease is to be differentiated from pruritus and 
hyperesthesia of the skin, as also from the affections of deeper parts, 
muscular, nervous, aponeurotic, and visceral. Severe pain, limited 
strictly to the skin of the lumbar region, with hyperesthesia, may pre¬ 
cede the occurrence of perinephritic abscess. 

The treatment is to be directed to the disorder, of which, in the great 
majority of cases, the dermatalgia is merely a local symptom. Quiniu, 
the salicylates, iron, arsenic, and the phosphid of zinc are often indi¬ 
cated. Temporary relief, however, may be afforded by the local ap¬ 
plication of the rubber bag filled with very hot or very cold water; 
sometimes by an alternation of the two, each for a few moments at a 
time. Sponging of the part with very hot water is also useful, con¬ 
tinued for longer periods, and followed by swathing in cotton-batting 
covered with the Lister protective. The anodynes may also be used 
topically with advantage; especially cocam, opium, aconite, belladonna, 
or stramonium in oily combinations. In some cases relief is had by 
painting the parts with Squibb’s oleate of mercury and morphin, a 
preparation particularly well adapted to meet the indications presented. 
The skin should generally, in the interval of application, be protected 
by a dusting-powder; and the clothing worn next the skin should be 
of an unirritating character. Care should be taken in dermatalgias 
limited to the trunk of women, lest the corsets be responsible for the 
mischief. ' J ' 

The prognosis depends upon the nature of the cause of the abnormal 
sensations. In general it may be said that these cases are less per¬ 
sistent and annoying than those of confirmed cutaneous pruritus 
with melancholia. 


ANESTHESIA. 

(Gr. a, privative; ala-Q-rjcig, sensibility ) 

In this condition there is total or partial diminution of sensibility, 
with and without structural alteration of the skin. As in the affection 
just "described, the disorder may be either idiopathic or symptomatic, 


1 Phlla. Med. and Surgical Reporter, Jan. 18, 1881, p. 677. 


XE UR OSES. 


707 


general or partial, unilateral or bilateral, central or peripheral, and in 
varying grades of severity. Illustrations of the disease are furnished 
in the anesthetic patches of leprosy, which may or may not exhibit 
textural skin-changes, the disorder resulting from involvement of the 
nerves. Other diseases and conditions may be accompanied by partial 
or total loss of cutaneous sensibility, including centric and eccentric 
paralyses; syphilitic, hysterical, and ataxic disorders; partial or com¬ 
plete anesthesia of artificial production; the several toxic narcoses; 
traumatism of nerves by pressure, wound, or contusion; the local anes¬ 
thesia induced by cold, frigorific mixtures, and substances capable of 
benumbing the sensitiveness of the skin; coma, of whatever origin; 
and a number of idiopathic cutaneous disorders, including several of 
the atrophies, scleroderma, and morphea. 

A curious divorce occasionally obtains between the elements which 
together constitute the compound sensory impression derived from the 
touch. The recognition of pain, of degrees of temperature, as also of the 
form, size, density, distance, weight, resistance, and other properties of 
foreign bodies, is accomplished largely by the sensory nerves; and the 
power to appreciate one or several of these objective qualities may in 
different degrees be impaired. In this respect several forms of what, 
for want of a better term, may be named “ cutaneous anesthesia,” 
are comparable to the conditions recognized in color-blindness. Thus, 
in some cases, there is appreciation of heat, but not of cold; of form, 
and not of weight; of pain, and not of objective qualities; and the 
reverse. A curious illustration of this occurred in the person of a leper, 
whose hands were in all parts quite sensitive to the prick of a lancet 
and to contact with heated substances; yet who exposed them for 
hours, without protection, to an atmospheric temperature of ten degrees 
below zero, without becoming aware of even slight discomfort. 

The neuroses described above are those of sensibility. Unquestion¬ 
ably there are, besides these, a number of cutaneous affections popu¬ 
larly termed “neuroses,” which require mention in this connection. 
Unfortunately, in the present state of the science, it is not certainly 
determined to what special class these affections should definitely and 
permanently be assigned. Some of them have already been described 
in these pages. In what follows there is attempted a schematic 
classification of the symptoms displayed in all, without endeavoring 
to discriminate between the parts severally played in each by nerve, 
vessel, and tissue. 


VASO-MOTOR AND TROPHIC NEUROSIS. 

Under the first of these titles, Schwimmer discusses erythema mul¬ 
tiforme, herpes iris, erythema nodosum, urticaria, and the medicinal 
erythemata; under the second, prurigo and herpes (simplex and zoster). 

It is, however, to phenomena of a different character that in these 
pages attention is directed by these terms. These symptoms are, for 
the most part, symmetrical in distribution, and largely limited to the 
hands and feet, though in some instances, with or without implication 


708 


DISEASES OF THE SKIN. 


of these organs, other parts are invaded, most often the mouth, next 
the scalp, lastly the trunk. The four groups named below are readily 
recognized. 

In a first group the symptoms are chiefly functional, invading the 
feet alone, or the hands alone, or both the hands and feet, the symp¬ 
toms predominating either in the one or the other. These symptoms 
are symmetrical hyperidrosis, anidrosis, bromidrosis; coldness of the 
organs; and symmetrical asphyxia (“ dying ” of the hands or feet, when 
immersed in cold water, digiti mortui). With the local phenomena 
may occur sudden attacks of faintness or of giddiness; a pulse ranging 
from very slow to very rapid action, and rheumatoid pains. Many of 
these symptoms are associated with those next described. 

In a second and larger group may be collected the symmetrical struc¬ 
tural changes in the skin and its appendages without destructive degen¬ 
eration, cutaneous or subcutaneous in situation. With these symptoms 
may be associated the blueness, coldness, or wetness of the organs, 
referred to above. One or several, usually, of the nails may here be 
involved, these appendages becoming rough, dry, lustreless, friable, or 
gryphotic. They are usually tilted away anteriorly from their nail- 
beds by a corneous deposit visible beneath the free border. Here, also, 
may be enumerated, symmetrically arranged, livid or reddish blotches; 
erythematous, vesicular, and scaling patches; localized hypertrichoses 
and alopecias (of the legs chiefly); tyloses of palms and soles (in cases, 
with recurrent slough of the callosity); and local anesthesias. The 
Bleeding Stigmata which attracted the attention of the French and 
Belgian authorities from 1873 to 1875, belong to the same category, 
as also the “ Glossy Fingers” of Paget ( q . v.). 

In a third group may be placed the phenomena of Raynaud’s dis¬ 
ease, the cases of symmetrical ulcerative and degenerating lesions not 
necessarily fatal, including “perforating ulcer of the foot” (malum 
perforans pedis, q. v.). Here are classed the cases described by Atkin¬ 
son as “ multiple cutaneous ulceration,” and the well-known cases of 
Eichoff, Boeck, Simon, Weiss, and Hutchinson. 

Leloir and Hejerine presented a case of this character at a recent 
meeting of the Soci^te de Biologie, in Paris. A young girl, several 
members of whose family were affected with nervous disease, developed 
on the cheeks, without an apparent cause, several patches of superficial 
gangrene; the smaller eschars soon separated, leaving a linear cicatrix, 
which gradually became transformed into keloid elevations. The first 
lesions appeared three years before, and during this period she had 
suffered from similar patches on the trunk and arms. They began on 
the skin by a sensation of pricking, with slight redness and notable 
diminution of sensibility at this point; in nine hours a white patch, 
not preceded by phlyctenulae, formed and underwent after a short time 
superficial gangrene. Later the spot became brownish, detached at the 
edges, and was finally eliminated, leaving an ulcer and a cicatrix, the 
anesthesia which existed around the part finally disappearing. 

In a fourth and final group may be set the cases which end fatally, 
in consequence of an apparently lethal tendency of the disease from 
the first. Here may be cited Hutchinson’s “ Form of Inflammation 


NEUROSES. 


709 


of the Lips and Mouth, which sometimes ends fatally, and is usually 
attended by some Diseases of the Skin;” and a list of affections with 
cutaneous symptoms chiefly studied by neurologists, including the pied 
tabetique of Charcot; cases of posterior spinal sclerosis; and others of 
syphilitic, tuberculous, and rheumatic disease of the cord and men¬ 
inges. 1 

The pathology of many of these disorders is clear, changes in the 
central and peripheral nervous tracts having been found sufficient to 
account for the phenomena (absence of axis-cylinder; thickening of 
neurilemma; increase of endoneurium). In some cases no lesions of 
the nerves have been recognized, and authors have not been wanting 
who regarded some of the disorders named above as u purely local” 
in character. 2 


MYXEDEMA. 

(Gr. fivtja, humor; olteo, to swell.) 


(Cretinoid (Edema. Fr. t Cachexie pachydermique.) 


Myxedema is a disease chiefly of women, characterized by a constitutional cachexia^ 
which usually results in the production of a cretinoid state, and is accompanied 
by a characteristic pachydermia. 


This disorder was first described by Sir William Gull, 3 in 1873; 
and it has since been observed, both abroad and in this country, by 
competent observers, including Ord, 4 Mahomed, 5 Hadden, 6 Stokes, 7 
Hammond, Horsley, Ballet, Ball, 8 and others. 

The most complete description of the disease and resume of the 
literature to date is found in the report of the Clinical Society of 
London for 1888. The report embodies the results of the researches 
of a committee—including Ord, Horsley, and others specially ap¬ 
pointed by the Society to investigate the subject. 

Symptoms. The disease occurs in both acute and chronic manifesta¬ 
tions, usually after the fortieth year, and in women more often than 
in men. It may, however, first be noticed in childhood. 

At the outset there is observed a persistent and remediless anemia, 
gradually succeeded by mental hebetude, sluggishness of bodily move¬ 
ments, and a characteristic change in the integument. The skin becomes 
dry, yellowish, waxy, translucent, firm, and refuses to pit on moderate 
pressure, the mucous membranes often participating in the morbid pro¬ 
cess. In the cheeks there is usually perceptible a brawny redness; de¬ 
fined at times as a sharply circumscribed, pinkish flush extending quite 
to the lower evelids, which may, as in Ball’s cases, be wrinkled, boggy, 
and swollen/ The eyes, for this reason, seem smaller than natural 
and more widely separated. In consequence of the swelling and 


1 See the author’s paper on “ Symmetrical Hand and Foot Disease,” read before the American 

B ?ForTcS^ «f «■» Stln ' see Leloir ’ s cha I> ter 0n Derma - 

\ 1878 - v - p - 57 ' 

? N? Y d Med? Rwortfjuly 10, 1886. * British Med. Journ., Oct. 16, 1886. 


710 


DISEASES OF THE SKIN. 


immobility of the features, the facies is characteristic: the broad, thick 
nose; swollen, pendulous, or even everted lips; expressionless eyes; 
and leathery cheeks, producing upon the observer the impression of 
a mask. The skin of the other regions of the body participates in 
these changes. The mucous membrane of the mouth (gums, palate, 
pharynx) becomes tumid and fungous. 

In the triangles at the side of the neck, and also at its back, are 
“ bolsters” of fat. The hair of the head becomes harsh and scanty; 
alopecia may be complete. Pigment-alterations readily occur; moles 
increase in size; and the general tint of the skin may vary from that 
of dry parchment to the hue of Addison’s disease. The gait is wad¬ 
dling and uncertain. The thyroid gland atrophies. Anesthesia is of 
common occurrence. The tongue, uvula, and fauces are often so thick¬ 
ened and immobile as to make speech both slow and indistinct. 

The course of the disease is chronic, lasting for years and terminat¬ 
ing usually in a state of marasmus with fatal issue. 

Etiology. The cause of myxedema is imperfectly understood, though 
its association with abolition of the thyroid gland (after pathological 
change or ablation) is generally admitted. Stokes reports ten cases of 
acute myxedema following thyroidectomy. In these cases, beside the 
rapid occurrence of the symptoms enumerated above, there were con¬ 
vulsive seizures of an epileptiform character. Of four hundred and 
eight complete thyroidectomies analyzed in the Clinical Society’s 
report, in sixty-nine myxedema developed. It did not develop when 
a part of the gland was left. The influence of heredity is distinctly 
shown in cases reported by Ball, Ord, Saville, and Taylor. One hun¬ 
dred and one of one hundred and twenty-one cases collected by Ball 
occurred in women. The disease may affect children, but is more 
common in individuals of middle life. 

At the present date it is undetermined what relations, etiological 
or other, subsist between the members of an interesting group of mala¬ 
dies, all characterized by cutaneous changes or dystrophy of the appen¬ 
dages of the skin, and total or partial abolition of the functions of the 
thyroid gland. In this group are to be named not merely myxedema, 
but also myxedematous cretinism, acromegaly, and Graves’s disease. 
These maladies are denominated by some authors the “ thyroid 
cachexias.” 

Pathology. The disease seems to be due to the deposit of mucin, 
or u animal gum,” in the meshes of the connective tissue. This 
mucinoid degeneration may iuvolve the pneumogastric, glosso-pharyn- 
geal, great sympathetic, and other nerves. The psycho-cortical centres 
are unquestionably similarly involved. In the skin the fibrillse of 
connective tissue multiply, their nuclei becoming large and distinct. 
The mucin-yielding cement-substance between these fiblillse appears in 
large amounts in the interstitial spaces. In a post-mortem examina¬ 
tion made by Ord it was estimated that the skin contained fifty times 
the normal amount of mucin. 

Diagnosis. Cases of myxedema are readily distinguished from 
those of elephantiasis by the generalization of the symptoms, the ner¬ 
vous state of the patient, the fat-deposits, and the condition of the 


PARASITIC AFFECTIONS. 


711 


thyroid gland. Acromegaly involves the bones; in lepra, there are 
commonly anesthetic symptoms or characteristic tubercles. 

The treatment of myxedema has hitherto sought amelioration of the 
symptoms by the employment of roborant and tonic measures; alka¬ 
line and sulphur baths; electricity and massage. The later method of 
treatment, however, is by administration of thyroids. 1 Whether there 
be employed the gland itself of the sheep, or the powder skilfully pre¬ 
pared by evaporation, or Vermehren’s extract precipitated by alcohol, 
the results are satisfactory in so large a proportion of cases that the 
prognosis of this group of disorders promises to be, in the near future, 
very greatly improved. The headache, faintness, loss of weight, neu¬ 
ralgias, and even albuminuria, with other symptoms immediately 
following the employment of the thyroids named above, do not seem 
to have any adverse influence upon the remoter benefits received from 
the treatment. 


CLASS VIII. 


PARASITIC AFFECTIONS. 


The cutaneous disorders of this class possess many features in com¬ 
mon with those already described. In them, as in others, are observed 
the hyperemic and exudative processes which result in surface-lesions 
of similar type and career. They differ, however, from other affec¬ 
tions of the integument, in that they are all induced by parasites of 
either vegetable or animal origin; and are, as a consequence, com¬ 
monly characterized by certain special features. They involve the 
skin and its appendages, their symptoms being at times displayed 
chiefly in the integument proper, and at other times in one or more of 
the cutaneous appendages, according to the mode of propagation and 
attack, peculiar in each case to the parasite present. They are all in 
different degrees contagious; and, being induced by local and tangible 
causes, are usually relieved by external treatment. Their importance 
in cutaneous medicine rests not only upon the facts named above, but 
also upon the too general misconception regarding their nature, since 
there are many patients treated by internal remedies, ingested vainn 
for long periods of time, who are yet suffering from parasitic disorders 
often remediable by very simple local measures. 

It should not be forgotten, however, that, distinct though these mal¬ 
adies be in an etiological sense, they are yet often practically com¬ 
mingled with others. Thus, an eczematous scalp m a child may by 
accident become the habitat of lice; and the eczema induced originally 
by the acarus seabiei may long persist after the destruction ot the 

^Thtfterm tinea, derived from a Latin word meaning “a moth or 


, See a valuable paper on this subject, “ Feeding Thyroids in Myxedema,” by J. J. Putnam. 
Amer. Journ. of the Med. Sciences, August, 1893. 


712 


DISEASES OF THE SKIF. 


worm,” has by common consent been adopted as a generic designation 
of all the cutaneous disorders induced by the presence of vegetable 
organisms. 


1. DISORDERS DUE TO VEGETABLE PARASITES. 

TINEA FAVOSA. 

(Lat .favus, a honeycomb.) 

(Honeycomb Ringworm, Porrigo Favosa, Favus. Fr., Teigne 
faveuse; Ger., Erbgrind.) 

Statistical frequency in America, 0 286. 

Tinea favosa is a contagious disease of the scalp, and less frequently of other por¬ 
tions of the surface of the body, characterized by pea- to coin-sized, sulphur- 
yellow, and umbilicated crusts, commonly traversed by hairs, and produced by 
the invasion of a vegetable organism, the achorion Schonleinii. 

Symptoms. Favus affects chiefly the scalp, but it also occurs upon 
the so-called “ non-hairy ” portions of the skin and upon the nails. 
In the former situation it is usually first recognized by the develop¬ 
ment of minute, subepidermic, yellowish or reddish puncta, visible 
through the translucent stratum corneum at the site of implantation 
of the hairs. A peripheral circle of delicate vesicles may surround 
these spots. Puncture with a needle usually gives exit to a puriform 
matter. In the course of a fortnight or more these lesions cover them¬ 
selves with pea-sized and somewhat larger, friable, circular, and ele¬ 
vated crusts, having the yellowish tinge of the lemon or of sulphur, 
and a concavo-convex shape, with the free concave face of the disk 
exposed. At the centre of the umbilication thus presented to the eye 
one or several hairs usually make exit to the surface. The inferior 
surface of this disk, or scutulum, rests upon the scalp, which is either 
moist and deprived over a circumscribed area of its epidermis, or is 
smooth, dry, reddened, and tender. When the crust is removed 
by traction upon the hairs or otherwise, a minute cup-shaped depres¬ 
sion is left at the point where the lowest level of the favus crust was 
in intimate connection with the epidermis. 

The subsequent features of the crusts, the hairs, and the scalp are 
subject to some variation. The crusts may acquire a brownish or a 
greenish tinge by admixture with dirt or with dried pus; may coalesce 
(favus squamosus); or may, by gradual desiccation, exchange the yel¬ 
lowish hue for the dirty-whitish shade of old mortar, a substance which 
they then resemble in dryness and friability. The hairs invaded both 
in the sheath and shaft may lose their lustre; become fragile; appear 
as fractured relics of longer filaments; readily be extracted from their 
follicles ; and finally be shed, leaving behind hair-sacs destined to fall 
into atrophy, and incapable of reproducing a pilary growth. The 
scalp may first be the seat of an extensive hyperemia or exudation 
going on to the formation of pus, when the fungus is a source of acute 


PARASITIC AFFECTIONS. 


713 


irritation in consequence of its active development. Later, when its 
destructive work may be said to have been accomplished, the scalp- 
surface is bald, irregularly atrophied, or disfigured with minute cicatrices, 
while here and there remain tufts of hair which have survived the attack. 

The lesions may be discrete or be confluent, and may vary in either 
case. Occasionally but a few small and ill-developed crusts form upon 
the surface The entire scalp is not often covered with a confluent 
favus-crust. The disease is usually chronic in its course. Untreated, 
it may undergo spontaneous involution after total destruction of all 
hairs and production of general follicular atrophy, but this is rare. 
It may last for fifteen or twenty years, and even longer. It is often 
accompanied by adenopathy. 

The disease usually awakens a noteworthy degree of itching, and, 
as a result, it is not rare to find the favus-crusts torn and broken by 
the comb or the nails. 

The yellowish disks of the disease occur also in typical develop¬ 
ment, though more rarely, upon the surface of the face (including the 
bearded cheeks, lips, and chin), and upon the trunk and extremities. 
Fox, of New York, has photographed a patient’s knee which was 
covered on its extensor aspect with favus-crusts. 

When the nails are invaded, light or deep yellowish, circumscribed 
spots become visible through the nail-structure, and by the extension 
of these, in consequence of the growth of the parasite, the nail-tissue 
may be thickened, irregularly split, laminated, separated from its 
matrix, or atrophied. The complication is rare, and is supposed to 
be due to the transfer of the parasite from the scalp to the hands in the 
act of scratching. When it exists, the epidermis fringing the nail is 
usually also involved. 

Upon the so-called “ non-hairy ” portions of the body favus occurs 
in the same forms as elsewhere, the localities in the order of frequency 
being those most exposed to the hands charged with the parasite, or 
to other sources of the disease, viz., the hands (chiefly the backs and 
nails), the upper and lower extremities, and the shoulders. It is a 
striking fact that favus may exist for years on the scalp without spread¬ 
ing elsewhere. At a clinic for practitioners in Chicago were exhibited 
five patients affected with favus, all scalp cases, the eldest, a male, 
twenty-five years of age, who had suffered from the disease for twenty 
years without occurrence of the lesions elsewhere. 

In favus of the body-surface, outside the scalp, there is ofteu a 
resemblance to ringworm in the production of circular patches with 
an active border made up of vesicles or of papules, which may have a 
favus scutulum as a centre; or several of these cups may irregularly 
be spread over circles of scaling patches. In these cases there is often 
an acuity of symptoms not observed in scalp cases and coincident gastro¬ 
intestinal signs of irritation, vomiting, etc., which Kundrat believes 
may originate in favus of the mucous surfaces of the cesophagus and 

gastro-intestinal tract. . . . 

The odor of fully developed favus is so characteristic that by it 
alone a diagnosis has been established. It is usually compared to the 
odor of mice; also to that of the urine of cats. It should not be con- 


714 


DISEASES OF THE SKIN. 


founded with the peculiarly disgusting odor of many neglected scalps 
affected with lice or covered with pustules and filth. The disease 
not infrequently coexists with other cutaneous, parasitic, and non- 
parasitic diseases, as, for example, seborrhea, eczema, and tinea ton¬ 
surans. 

Favus of the Nail (Favic Onychomycosis). Rarely, one or 
several of the nails may be the seat of the fungus, and either the 
entire body of the nail or but a part of it. The lesions are maize- 
yellow points or macules where the substance of the organs is eroded, 
fissured, or split into striations—changes quite like those induced by 
other causes. The connections of the nail with the underlying nail-bed 
and nail-folds are loosened, wholly or in part, while the matrix still 
holds the nail firmly in position. 

Under the microscope minute collections of spores surrounded by 
branching mycelium of the achorion are recognized in isolated points 
or in diffuse patches in epidermic scales scraped from the surface. 
The fungus never penetrates within the papillary layer, but ramifies 
to a varying extent in different cases in both the upper and lower 
portions of the rete. 


Fig. 92. 



Achorion Schiinleinii: a, spores; b, c, sporophores (after Cornil and Ranvier). 


Etiology. Favus is always produced by the presence and develop¬ 
ment of the vegetable organism which is named after its discoverer, 
the achorion Schonleinii (Fig. 92). It is a contagious disease simply 
because the parasite which produces it is capable of transmission from 
man to man, as also from animals to man, and vice versa. It is often 
conveyed to man from mice, cats, dogs, rabbits, fowls, and ponies; 
but when derived from the lower animals, is most often transmitted 
from mice to cats and from cats to man. It shares with other diseases 
originating from vegetable parasites, the peculiarity of attacking certain 
individuals specially predisposed to such invasion, either by reason of 
physical peculiarities of organization or accidental and fortuitous cir¬ 
cumstances. It is most common from infancy to the thirtieth year of 
life. It is rare in the United States, Austria, and England; and more 


PARASITIC AFFECTIONS. 


715 


common in France, Scotland, and Poland. It is said by Bergeron 1 to 
be a disease of the country, while tinea trichophytina prevails in the 
cities. This statement is certainly corroborated by general experi¬ 
ence. Favus is more common in public than in private practice, and 
the larger number of clinical patients with favus come to the city from 
the country. 

Evidences of contagion are exhibited in those cases where several 
members of the same household are affected with the disease; but in 
other cases the absence of a history of contagion after exposure indi¬ 
cates the relative difficulty experienced in propagating the contagious 
element in the case of favus. Thus, one individual, exposed among 
a dozen who are diseased, will fail to exhibit any favus-crusts; and the 
latter by no means form in all situations of the same body where the 
fungus can be discovered by the microscope. Aubert, 2 indeed, presents 
an argument in favor of the production of the disease by traumatism, 
the resulting wounds, excoriations, etc., becoming by accident the seat 
of the disease. It is not very rarely discovered under poultices and 
fomentations. 

Occasionally favus occurs in special localities with such development 
among men and the inferior animals as to constitute an epidemic. 
Girard 3 reports thus the simultaneous existence of the disease among 
sixteen cows and four children in the village of Nantoin, in France. 
It is propagated also upon the skin of rats and mice, from which it is 
transmitted to man, often through the medium of the domesticated 
cat and dog. 

Pathology. Uuder the microscope the fungus is readily recognized in 
the root-sheaths, the bulbs, and the shafts of the hairy filaments near 
the scalp. At a distance of about two inches from the bulb the parasite 
ceases to appear in the tissue of the hair. It is also seen upon the free 
surface of the skin. The favus-crust, softened by the addition of a 
little water or dilute liquor potassse, may be placed upon the slide of 
the microscope without other preparation for its study. . The hairs 
may be examined in the same manner or they may be stained by the 
methods given for staining the ringworm * fungi. Under a good 
one-fourth- or one-sixth-inch objective the vegetation is seen to be 
composed of intricate masses of mycelium and spores in great quantity. 

Quincke 4 attempted to distinguish between three varieties of the 
favus fungus, designated respectively as a , /?, and y. Elsenberg, Krai, 
Pick, Unna, and others have, however, arrived at different conclusions 
upon the same subject, some recognizing but two of Quincke’s forms; 
others, two separate forms not corresponding with the a, ft or y forms 
of Quincke; and still others, corresponding with none of those pre¬ 
viously described. The majority of observers agree that there is but 
one achorion fungus, displaying itself in several forms both under the 
microscope and clinically, all differences being due .to accidental influ¬ 
ences (varying amount of heat, moisture, and friction in the involved 
surface). 


1 Etude sur La Geographie et la Prophylaxie des Teignes, Paris, 1865. 

2 R61e de traumatism dans l’Etiologie de la Teigne faveuse (Ann. de Derm, et de Syph., April, 

18 3 1 Lyon Med., August 18,1880, p. 547. 4 Monatsheft f. prakt. Dermat., 1889, t. viii. p. 49. 


716 


DISEASES OF THE SKIN. 


The threads of the fungus usually preponderate, and appear as nar¬ 
row, flattened, ramifying, short or elongated, linear cells or tubes, 
which may be simple and empty, or be divided more or less regularly 
by transverse partition-walls, transforming the longer and simple into 
shorter and compound cells. The latter often contain in their cavities 
sporules clinging to either side, in which case the mycelial threads are 
termed sporophores. These sporules are the vegetative part of the 
cryptogamous fungus, and develop by multiple subdivision into cells, 
which may also themselves similarly increase in number, or by the 
production, at the terminal extremities of certain mycelial threads, of 
spores or conidia. The conidia are encapsulated or are strung together 
like the beads upon a necklace, and they appear as round, oval-shaped, 
angular, or very irregularly contoured bodies, often provided with 
partition-walls like mycelium, constituting thus compound cells. At 
the same time an amorphous granular matter can usually be distin¬ 
guished in the mass of the fungus. The hyphse vary in width from 
0.0023 to 0.0030 mm.; and the spores from 0.0023 to 0.0052 mm. 

Examination of the invaded scalp reveals, according to Unna, 1 
the presence of the fungus at the lower border of the upper three- 
fourtlis of the root-sheaths, where chains of conidia appear among the 
histological elements. His view is that the cuticle of the hair offers 
a relative resistance to the growth of the vegetation; that the latter first 
penetrates the stratum corneum and the follicular orifice, and then 
stretches, upon the one hand, into the cortex and medulla through 
the cuticle of the hair; and, on the other hand, passes to the inner 
root-sheaths, the outer remaining always intact. In the epidermis, 
the fungus is found chiefly between the superficial and deep portions 
of the stratum corneum. The superior pars vascularis of the corium 
exhibits enlarged vessels surrounded by inflammatory elements. 

When the nail is involved the parasite may be recognized in the 
debris produced by scraping the nail-substance ; often also in the 
epidermis bordering the nail. The fungus exhibits here the same 
microscopical features as upon the scalp, though, in consequence of the 
denser structure of the nail-substance, its vegetation is usually less 
luxuriant. 

Diagnosis. The clinical recognition of favus is based upon the 
presence of the characteristic, yellowish, cup-shaped crusts, often aided 
by a history of contagion, and the peculiar odor emanating from the 
scalp. The secondary effects upon the hairs, hair-follicles, and skin, 
are also, when present, significant. White, of Boston, in a valuable 
essay on the u Vegetable Parasites, and Diseases caused by their 
Growth upon Man,” calls attention to the stage in which the disease 
is likely to be mistaken for ringworm. It exists before the formation 
of the crust, and may be characterized by hyperemia, vesiculation, or 
papulation, often unnoticed beneath the hairs of the scalp. In doubt¬ 
ful cases the microscope will usually establish the diagnosis, though 
Bodiu, Morris, Sabouraud and other recent observers think it is not 
always possible to draw a sharp line between favus and ringworm, 


1 Viertelj. f. Derm. u. Syph., vii. p. 170. 


PARASITIC AFFECTIONS. 


717 


and that cases occur in which it is impossible —with the means now at 
our disposal—to make a differential diagnosis with precision. 1 

Aubert, 2 in the absence of the clinical features named above, lays 
stress upon an intense redness of the scalp where the hairs have been 
cut and the crusts removed, this color being limited to the portions 
attacked by the disease. The hairs, also, as a result of the disin¬ 
tegration of their elements, are infiltrated by air, and look opaque 
and black by transmitted light; by reflected light they appear pol¬ 
ished and stratified. It should not be forgotten that in exceptional 
cases favus-crusts coexist upon the body with other diseases of prior 
or of subsequent origin, as indicated. The disease should not be 
confounded with seborrhea, pustular eczema, or psoriasis of the scalp, 
none of which exhibits the special features of a parasitic fungus. 

Treatment. The first indication in the treatment of favus is to cleanse 
the affected surface from all favus and other crusts and scales which 
may be present. For this purpose the scalp (if this be, for example, 
the affected part) is first shorn of its hair with scissors, and is then 
thoroughly soaked in olive, cod-liver, or other oil, or in glycerin. 
After this treatment all the crusts are scraped away with a spatula, 
and the scalp is washed clean with hot water and soap, the spirit of 
green soap being here preferably used. The scalp should then again 
be anointed with oil, or be covered with an emollient poultice. Once 
thoroughly cleansed by repeated soakiugs in oil and by ablutions, it is 
necessary to resort either to the topical employment of parasiticides 
(agents capable of destroying the fungus) or to epilation (the extraction 
of the hairs). Often both measures are required. Without further 
treatment, the scalp, however completely freed from all evidences of 
the disease, will not fail to show fresh favus-crusts in a fortnight or 
somewhat longer time. 

Epilation is practised by the aid of epilating-forceps. These forceps 
should be constructed with an easy spring that will not tire the fingers 
of the operator; with blades that are sufficiently broad to grasp a few 
hairs at once; and with smooth, or but slightly serrated faces of the 
blades, as otherwise the hair is liable to fracture in the grasp of the in¬ 
strument. The surface to be operated upon should previously be 
anointed with vaselin or with olive oil, and the hairs entirely be re¬ 
moved, a sufficient number, covering a definite space, upon successive 

The tediousness of this process has \ed to several devices by which 
it is sought to do away with its necessity. Originally the “ calotte 
was employed for the removal of the hairs; it was made by smearing 
a disk of leather with pitch, and applying it over the scalp. When 
the calotte was subsequently removed by a brisk motion of the hand, 
the hairs which adhered were forcibly uprooted en masse ; those remain¬ 
ing being adherent in their sacs in consequence of the fact that they had 
not been invaded by the fungus. As a substitute for this somewhat 

i For literature on the subject see references given under the introductory paragraphs on ring- 

W 2 r Annal. de Derm, etde Sypb., 2e. ser., 11, p. 34. 


718 


DISEASES OF THE SKIN. 


brutal procedure, Bulkley 1 employed adhesive masses, or sticks, which 
can be melted and be made to adhere at once to large numbers of the 
hairs. When cold they can be withdrawn from the surface with the 
hairs attached. These sticks are from two to three inches in length, 
and from one-fourth to three-fourths of an inch in diameter. 1 he 
hair is first clipped so as to be about one-eighth of an inch in length. 
The end of the stick is then heated in an alcoholic flame, and quickly 
placed upon the scalp. It is thus left in place until quite cold, and is 
removed by bending it over and drawing upon the hairs successively 
with slight rotation. When free it is found thickly set with the ex¬ 
tracted filaments, which may be burned off in the alcohol flame, 
thus destroying both the hairs and any adherent fungous masses. The 
stick is then carefully wiped clean with paper, after which it is again 
ready for use. The formula for the mass of which these sticks are 
composed is as follows: 


-Cerae fiavae, 

3 fib 

12 

Laccae in tubulis, 

3 iv ; 

16 

Resinae, 


24 

Picis Burgundicae, 

3*j; 

44 

Gummi dammar., 

3jss; 

48 


The parasiticides in greatest favor are : corrosive sublimate in solu¬ 
tion in the strength of from 1 to 4 grains (0.066-0.266) to the ounce 
(32.); sulphite of sodium in saturated solution; pure or diluted sul¬ 
phurous acid; spirit of green soap; chrysarobin, pyrogallol, tar, croton 
oil; boric, carbolic, and salicylic acids; petroleum, chloroform, ether, 
creosote, and the oil of cloves. The addition of acetic acid to liquid 
applications, or washing the surface with vinegar immediately before 
applying the parasiticide, is said to aid the penetration of the remedy. 
Ointments are also useful containing mercury (citrin ointment, yellow 
sulphate, or white precipitate), naphtol, benzol, thymol, sulphur, 
pyrogallol, salicylic and carbolic acids. Chrysarobin is very effective 
in an ointment, though objectionable on account of the staining of the 
scalp, and, almost inevitably, of the face also. Lenzberg 2 generates 
sulphur fumes in a dish of red-hot coals attached to a frame (made of 
wood or of pasteboard) close to the head of the patient. By means 
of a paper cap the fumes are collected and retained (from five to ten 
minutes) in contact with the patient’s hair. During ten years’ trial 
of this plan he has never been compelled to resort to epilation. 

One or more of the methods may be needed, either at the same time 
or by repetition or alternation, until the fungus is entirely destroyed, 
the requisite period usually extending over three months. Treatment 
should then be discontinued in order to test the result by observation. 
If, in the course of a fortnight or more, a relapse occurs, the treatment 
is to be promptly renewed. Upon the non-hairy portions of the body, 
parasiticides thoroughly applied usually procure a radical relief. When 
the nail is involved, it should be cut short and carefully scraped or be 

1 Favus and its Treatment by a New Method of Depilation. Archives of Dermatology, vii. No. 
2, April, 1881. 

2 Der prakt. Arzt., February, 1881. 


PARASITIC AFFECTIONS. 


719 


softened by repeated applications of a strongly alkaline lotion, after 
which a parasiticide may be employed in ointment or lotion. 

In general, it may be remarked that patients long affected with rebel¬ 
lious favus may need a roborant course of treatment and nutritious 
diet. Cleanliness here, as in all the parasitic disorders, is essentially 
important. As adjuvants in the treatment of the scalp and nails, it is 
well to remember that continuous applications of a parasiticide are 
aided by caps or cots of impermeable material, superimposed upon 
rags saturated with the medicament employed. For use in this man¬ 
ner, and especially for the nails, Sabouraud recommends a solution 
containing one gramme of iodin and two grammes of potassium iodid 
in a litre of distilled water. 

Prognosis. The prognosis is generally favorable to the ultimate 
termination of the disease in all cases; for even the most rebellious 
and untreated forms are relieved when the hair-follicles atrophy. 
Upon the non-hairy portions of the body the disorder is rarely severe 
if promptly and efficiently treated. Upon the scalp the prognosis is 
proportioned to the exteut, severity, and period of prior invasion of 
the disease. Early and vigorous treatment of the scalp in healthy 
children is usually followed bv satisfactory results. In long-neglected 
subjects of the disorder the result may be a remediless and character¬ 
istic baldness, the affected surface being provided with scanty wisps of 
short, stunted, and uncolored hairs. Neglect, filth, and systemic mal¬ 
nutrition are the most unfavorable elements in any case. 


Tinea Tricophytina. 

(Gr. Opi%, hair ; tyvrdv, a vegetation.) 


(Ringworm.) 

Statistical frequency in America, 1.85. 

Ringworm is a disease of the hairs and hair-follicles of the scalp 
and the beard, as also of the non-hairy portions of the body. In 
each case it is produced by the presence of a vegetable fungus. 
Until recently all forms of ringworm, both of the hairy and non-hairy 
portions of the body, were supposed to be produced by a single fungus, 
the trichophyton. In 1891 Furthmann and Neebe first advanced the 
idea that there were two or more fungi responsible for the various 
manifestations of the disease. Within the last few years a number 
of investigators, headed by Sabouraud, in a series of elaborate re¬ 
searches, have more definitely settled the etiological value of these 
fungi. It seems to be established that there are at least two distinct 
and unrelated forms, capable of producing the appearance classed as 
ringworm: the microsporon Audouini or small-spored fungus, and the 
trichophyton , or large-spored fungus. Of the latter several varieties 
are recognized by Sabouraud and others. The microsporon appears 
under the microscope chiefly in the form of a large number of round 
spores, irregularly grouped or massed about the follicular portion of 


720 


DISEASES OF THE SKIN. 


the hair. Mycelial threads, large and branching, are also seen, chiefly 
within the hair. The sheath of spores surrounding the hair is often 
continued upward about the latter for one-sixteenth or one-eighth of 
an inch above its exit from the follicle, and in this situation can be 
recognized by the unaided eye as a whitish or grayish coating of the 
hair. 

Sabouraud states that the mycelial threads of the microsporon are 
all within the hair proper, and that after repeatedly dividing and sub¬ 
dividing they terminate on the outer surface of the shaft in fine fila¬ 
ments at the extremities of which are the spores, which in this fungus 
are entirely external. In France the microsporon is responsible for 
about 60 per cent, of all cases of ringworm of the scalp in children. The 
fungus is not found in ringworm of the beard or of the body except in 
the form of small, irregularly outlined, slightly reddened, and furfura- 
ceous patches, occurring on the face and neck in children having ring¬ 
worm of the scalp; occasionally on the skin of adults who come in 
contact with such children. Such lesions of the skin do not at all 
resemble ordinary ringworm, as their outlines are irregular and ill- 
defined, and they rarely persist for more than a few days at a time. 
Sabouraud has never found the microsporon in kerion. 

The trichophyton is composed of spores which vary greatly in size, 
but which, as a rule, are considerably larger than those of the micro¬ 
sporon. They are frequently cuboidal, oval, or irregularly rounded, 
but their chief characteristic lies in their arrangement in lines or chains, 
extending up and down the hair-shaft. The mycelium is found with¬ 
out but never within the hairs. The trichophyton occurs in three varie¬ 
ties : the endothrix, in which the spores are found wholly within; the 
ectothrix, in which the spores are found wholly without; and the endo- 
ectothrix, iu which the spares are partly within and partly without the 
hair. The endothrix, like the microsporon, is found only in ring¬ 
worm of the scalp of children, though it also may produce transient, 
inconspicuous, irregular, furfuraceous and slightly reddened patches 
on the face and neck of children affected with this form of ringworm. 
On the scalp the endothrix produces lesions which are often distinctly 
different from those caused by the microsporon. These differences are 
noted in the following pages in the clinical description of tinea tonsu¬ 
rans. The ectothrix and the endo-ectothrix are derived either directly 
or indirectly from the domestic animals, and are responsible for ring¬ 
worm of the body, of the beard, and of all suppurating forms of the 
disease. By means of culture-experiments a number of subvarieties 
of the trichophyton are differentiated, many of which, however, are not 
accepted by other observers than Sabouraud. These varied appear¬ 
ances are looked upon by some as the result largely or wholly of differ¬ 
ences in the media and circumstances of cultivation. It is well kuown 
that slight modifications of the culture-media produce marked changes 
in the character of a fungus-growth. 

Iu London, Morris, Fox, Adamson, and others, find the micro¬ 
sporon is responsible for more than 90 per cent, of all cases of ring¬ 
worm of the scalp in children, and that it also occurs in some cases of 
ringworm of the body, and even in some of the suppurating forms of 


PARASITIC AFFECTIONS. 


721 


the disease, as kerion. The trichophyton is comparatively rare in Lon¬ 
don. On the other hand, Mibelli states that the microsporon is almost 
unknown in some parts of Italy, and it would seem to be equally rare 
in some portions of Germany. Sabouraud mentions particularly the 
fact that these fungi seem to have a definite geographical distribution, 
and that it is not at all strange under the circumstances that observers 
working in different countries should arrive at different conclusions. 

To prepare a hair for examination, it may be placed at once between 
a slide and cover-glass in a solution of potassium hydrate. Sabouraud 
uses a 25 to 40 per cent, solution, which is admirable for rapid work, 
but which quickly disintegrates the hair. Adamson employs a 5 or 
10 per cent, solution, which clears the hair slowly in the course of one 
or several hours. By making frequent examinations of the specimen 
the observer can arrest the destructive action of the solution at any 
stage desired, and thus better preserve the relative position of the fun¬ 
gus to the hair. Many attempts have been made to stain the fungi, 
which unfortunately show an affinity for the same stains as does the 
cortical layer of the hair. A very satisfactory method has been 
devised by Morris and his laboratory assistant, Calhoun. It is a 
modification of the Gram and AVeigert stain for bacilli, and gives 
good results. The hair is first washed in ether to remove all fatty 
d6bris; it is then put for one or two minutes in the Gram iodin solu¬ 
tion, and after drying is stained for from one to five minutes in 
gentian-violet and anilin water. It is again dried and treated for a 
minute or two with the iodin solution, and for an equal length of time 
in anilin oil containing pure iodin, after which it is cleared with anilin 
oil, washed in xylol, and mounted in Canada balsam. Coarse, dark 
hairs, and spores within the hairs require more time in staining than 
do fine, light-colored hairs and the fungus elements situated without 

the hair. . 

While the microscopical examination will often suffice to distinguish- 
the microsporon from the trichophyton or even for recognition of some 
of the varieties of the latter, the finer—and often disputed points of 
difference can be appreciated only by means of culture-experiments^ 
the details of which require fuller description than can be here given. 
The reader who wishes to pursue the subject further is referred to the 

appended bibliography. 1 . ,. 

These recent studies of the ringworm fungus, though interesting 
from an etiological standpoint, have as yet added little knowledge of 
practical value in the treatment of the disease, nor have they yet made 


i Sabouraud: Les Trichophyties Humaines, Pans, 1894, with Atlas. Diagnostic et traitement 
de la pelade et des teignes de l’enfant. Paris, 1895. 

Adamson : British Journal of Dermatology, Juiy, Aug., and Dec. 1895. , 1896 

Morris: Practitioner, Aug. 1895. “ Ringworn and the Trichophyton, London, 18%. 

Fox and Blaxall : British Journal of Dermatology, July, Aug., Sept., and Oct. 1896. 
Tmnsactions of the Third International Congress of Dermatology, London, Aug. 4 to 8,1896. 

P Hf R S 

server classifies the fungi according to their ability to digest horny tissues. 

M Fadyen: Journ. Path, and Bact., April, 1895. 

besTeignesSantofurtevSetleurInoculations humaines.” Paris, 1896 
Mibelli: Ann. de Derm, et de Syph., 1895, p. 733. 


46 


722 


DISEASES OF THE SKIN. 


sufficient progress to furnish a basis for a new and scientific classifica¬ 
tion of the different forms of ringworm. 

As each region of the body, when invaded by the parasite displays 
lesions which are more or less peculiar to itself, it is usual to consider 
each separately. Ringworm of the body is, therefore, designated 
Tinea Circinata; of the scalp, Tinea Tonsurans; of the beard, 
Tinea Sycosis. 


[A] Tinea Circinata. 

(Herpes Tonsurans, Ringworm of the Body. Fr., Hepes 
circin£, Tricophytie.) 

Statistical frequency in America, 0.569. 

Tinea circinata is a contagious disease of the skin, characterized by macular, vesicu. 
lar, papular, squamous, and rarely pustular lesions, having usually a clearly de¬ 
fined circular outline, and induced by the presence of the trichophyton. 

Symptoms. Ringworm of the body displays different symptoms, 
according to the temperature in which the vegetation flourishes, and 
the various external irritants to which the skin, where it has once been 
implanted, is subjected. 

The macular form of the disease is characterized by the occurrence 
of one or of several pea- to large coin-sized, circumscribed, reddish 
circles, usually paling under pressure, often at the general level of the 
integument, occasionally slightly raised above it, forming then a flat¬ 
tened disk. The centre of the circle may be paler, or indeed to the 
naked eye be quite unaffected, transforming the patch to an annular 
lesion, from which circumstance it originally received the name “ ring¬ 
worm.” It develops within certain limits, rarely exceeding five or 
six inches in diameter, by peripheral extension; and is usually charac¬ 
terized at the outer border by slight, whitish, furfuraceous desquama¬ 
tion. This form of lesion is usually seen upon exposed surfaces of 
the body where there is less heat, moisture, and friction, than upon 
other parts, as, for example, the forehead and neck in moderate atmos¬ 
pheric temperatures. From it may be developed the other forms 
described below. The disease may recur within the peripheral border; 
in this way occasionally two, three, and more concentric rings or par¬ 
allel bands of crescentic outline may be visible in a single patch of 
disease. Frequently a tendency to a peculiar formation, often that of 
concentric circles, is found in every patch existing at the same time in a 
given case. It is possible that the different types are produced by differ¬ 
ent species of the fungus. The subjective sensations are a trifling degree 
of itching or of burning. Should these rings extend to the beard or 
the scalp the circinate may coexist with the other varieties of the 
disease. 

The vesicular lesions of ringworm appear as such at the onset, or 
they rise from the macular lesions described above. In the former 
case, pin-point-sized, transitory, and superficial vesicles or vesico- 
papules spring from a central point or focus, or speedily shrivel until 


PARASITIC AFFECTIONS. 


723 


they are represented merely by minute, whitish, branny scales. To 
these lesions others succeed, always at the periphery, and to these again 
yet others, the rosy or the reddened base on which they rest being 
sometimes slightly in advance toward the outlying skin. The enlarg¬ 
ing circlets of disease proceed in their course to an evolution quite 
similar to that observed in the macular forms. The difference, due to 
a somewhat more active development of the fungus, is noted not merely 
in the type of the lesion, but also in the slightly exaggerated pruritic 
sensations which are awakened. Rarely, both of the forms described 
are presented with acute symptoms and extensive development, in 
multiple patches speading over the face, neck, trunk, and extremities, 
accompanied by a slight febrile movement and moderate tumefaction 
of the affected surfaces. As a rule, the eruption is trifling, and may, 
indeed, be limited to a single ring, or a very few circlets about the 
neck, terminating in the branny desquamation described; but in the 
severer forms the evolution of the disease may persist for months, and 
crusts form, whose fall leaves annular pigmentations of temporary 
duration. 

The papular and rare pustular forms of the disease observe the same 
peculiarities with respect to the clearing of the centre, the annular 
appearance of the advancing area of involvement, and the production 
finally of scales and crusts. They represent, however, either a much 
more luxuriant vegetation of the fungus, or the irritation of the affected 
part by friction and heat, or, what is probable, the co-operation of the 
two. They are, hence, most commonly observed upon the back, the 
belly, the inter- and infra-mammary regions, and the inner faces of 
the thighs and arms, in which localities they occasionally occur with 
chronic manifestations. The papules are light or dull-reddish, pin¬ 
head-sized and larger, solid elevations, roundish, oval-shaped, irreg¬ 
ular, or confluent, forming eventually bean- to coin-sized, raised disks 
with a pale, exfoliating, or actively inflamed centre, the so-called 
<< nummular erythema/’ or “discoid trichophytic erythema of 
French authors/ Some of the cases of “Conglomerate or Agminate 
Folliculitis ” have been found due to the trichophyton. The itching 
sometimes in these forms is severe; and the process may display cen¬ 
tral recrudescence, as noted above. Pustules found at the periphery 
have the size and distribution of the other lesions described, They 
represent merely an aggravated exudative process awakened by the 
fungus and the scratching incident to the pruritic sensations excited. 

Partly because of the controversy which the subject aroused, special 
attention was once directed to the disease which Hebra was first to 
name, Eczema Marginatum. It is most marked upon those portions 
of the body which come in contact with the saddle when a rider is 
mounted on a horse—that is, the perineum and the inner faces of the 
thighs, the region well marked by the reinforcing patch m the trousers 
of the cavalryman. The disease, as encountered here, is termed Iinea 
Trichophytina Cruris, and it occurs in both sexes. It is charac¬ 
terized by extensive exudation in bright or lurid patches, with a very 
distinctly defined, raised border, showing a sharp contrast with the 
healthy skin beyond, from which peculiarity it has its name. It may 


724 


DISEASES OF THE SKIN. 


extend laterally over the groins, upward over the pubes, and backward 
over the sacrum, being generally defined at the periphery by a cres¬ 
centic outline. The centre may be paler and less involved, or actively 
irritated, while the periphery still extends in one or more annular 
festoons down the inner side of the thigh or upward over the regions 
indicated. The itching is severe; the course of the disease is obstinate, 
persistent, and subject in a remarkable degree to relapse in the same 
locality. The fungus is always present, whether occurring as a cause or 
an epiphenomenon of the disorder. The disease was rightly named by 
Hebra, and it deserves special recognition under whatever title it may 
be classified. It is a true eczema, with special features, complicated by 
the development of the trichophyton, and, as is now well known, often 
by other representatives of the u dermatological flora.” It is aggra¬ 
vated by heat, the moisture of the sweat, and the friction of apposed 
surfaces of the skin in contact with each other and the clothing. After 
detecting the fungus in scales scraped from the surfaces thus involved, 
one is always in such case impressed with the characteristic clinical 
peculiarities of the disease. It is usually of symmetrical distribution, 
due to the circumstances of its development, and in this respect differs 
from the other manifestations of the disease. The condition may occur 
in milder forms in the axilla or about the breasts of women. In such 
cases it is indistinguishable clinically from a disorder described by 
Vidal under the title Circinate and Margin ate Pityriasis (pity¬ 
riasis circine et margin^), which he regards as due to microsporon 
anomoeon, or dispar. 

When the nails are affected, the disease is termed Tinea Tricho- 
phytina Unguium, or Onychomycosis. These appendages of the 
skin then become friable, opaque, and lamellated; and are clinically 
indistinguishable from nails secondarily changed in favus, eczema, 
psoriasis, and similar disorders of the integument. One or several of 
the nails of both the feet and hands may be affected. When all the 
nails of both extremities are involved the disease is rarely of parasitic 
origin. The microscope is requisite for establishing the diagnosis in the 
latter case, the parasite being detected in the fragments procured by 
scraping the nail. 

Etiology. Tinea circinata is caused by the presence of the parasite, 
though the latter may be an accident of other cutaneous disorders. 
The trichophyton was first discovered in 1844 by Gruby; though Malm- 
sten, whose name is often associated with that of the fungus, became 
identified with its recognition, by his observations during the succeed¬ 
ing year. As a contagious disease, it ranks higher in the scale than 
favus, being much more readily communicated, and, as a result, much 
more common. Occurring upon the non-hairy portions of the body, 
it is often spontaneously removed by the desquamative process which 
it excites in the skin. 

Though the fungus is the essential cause of the disease, its develop¬ 
ment is greatly favored or retarded by external influences. Attention 
has already been called to its luxuriance under the influence of heat 
and moisture. It is, therefore, much more severe and rebellious to 
treatment in tropical countries. It occasionally occurs in epidemic 


PARASITIC AFFECTIONS. 


725 


forms. Thus, Gerlier 1 gives the details of such an epidemic in Ferney- 
Voltaire, where twenty-six cases of the disease came under his obser¬ 
vation. In some of these instances the lesions were pustular, in others 
tuberculo-pustular. Aggravated forms of the disease often originate 
in the lower animals, the severest and most rebellious types being 
derived usually from the horse. Tinea circinata occurs much more 
frequently in children than in adults, presumably from the relatively 
tender condition of the epidermis in these subjects. It is particularly 
liable to occur in men whose skins are especially moistened, as in those 
who work in atmospheres saturated with steam. Several members of 
a single household will often display ringworm of the body at the same 
time, having transmitted it, the one to the other. The need of an 
appropriate soil for the germination of the fungus es shown by the fact 
that some individuals are predisposed to its invasion. It is, however, 
encountered in both sexes and in all social conditions. 


Fig. 93. 



Epidermis invaded by trichophyton: a, inferior portion of the stratum corneum; 6, superior 
portion of the rete. Both exhibit long mycelial threads, with a few ramifications and a small 
number of spores (after Kaposi). 


Pathology. The seat of the fungus in tinea circinata is between the 
strata of the epidermis, more particularly in the lower layers of the 
stratum corneum, and in the superior layers of the rete. Here 
the trichophyton can be discovered with the microscope, at an early 
stage of the disease, in the form of spores only; in the course of a 
few weeks exhibiting characteristic mycelium. The latter is much 
more scantily developed than in favus; much less branched and artic¬ 
ular- and the threads more slender. Like the elements m favus, 
however, these are jointed and divided into compound cells by 
partition-walls. The spores are also often strung together like the 

i Lyon Medical, April 24,1881, p. 590, and May 1, p. 7. 











726 


DISEASES OF THE SKIN. 


beads on a necklace. The former measure 0.0018 to 0.0026 mm ; and 
the latter, 0.0021 to 0.0035 mm. (Duhring). 

After the fungus has found its way to the surface of the skin favor¬ 
able to its development, it penetrates the layers of the epidermis in every 
direction from the central point of invasion, the circle thus produced 
being characteristic of many forms in both the higher and the lower 
vegetable life. The irritation excited by the presence of this foreign 
body produces all the subsequent symptoms of a mild grade of super¬ 
ficially seated inflammation, erythema, exudation, minute vesicles, 
papules, and, in severe grades, tubercles and pustules. The desquam¬ 
ative symptoms are exfoliative, and they represent, in a sense, the 
natural effort at relief; this effort, as noted above, being often success¬ 
ful when the spores and sporophores are thrown off with the effete, 
horny plates of the epidermis. When the nails are affected the same 
fungus can be discovered in detritus of the nail-tissue, which has been 
macerated in dilute liquor potassse. Often, as a result of the impair¬ 
ment of the structure of this organ, and owing largely to the stratifica¬ 
tion of its body, the lamellae will be found in part to have undergone 
a caseous degeneration. Sabouraud states that only the different species 
of trichophyton, “ectothrix pure,” or “ endo-ectothrix,” are found in 
ringworm of the glabrous skin and of the nails, though the “tricho¬ 
phyton endothrix” and the microsporon Audouini may be found 
occasionally in small, irregular, transient, reddened, scaling areas 
occurring on the face, neck, and other parts of the body during the 
course of ringworm of the scalp. 

Diagnosis. Ringworm of the body is to be distinguished, clinically, 
from eczema, psoriasis, seborrhea, lupus erythematosus, herpes iris, 
and syphilis. All the varieties of eczema are noted for their greater 
degree of itching and infiltration, their much less defined border, 
coarser scales, decided absence of a circular contour, and of a history 
of contagion. Psoriasis does occur in circular and annular patches, 
often with a clear centre and insignificant, subjective sensations; but 
its scales are lustrous and the tissue beneath them readily bleeds, show¬ 
ing deeper implication of the skin. The disease is often symmetrical 
in disposition; occurs by preference upon certain regions of the body 
where ringworm is relatively infrequent; and its history is that of a 
chronic disorder. Seborrhea of the skin exhibits greasy or fatty crusts, 
which are never characterized by the peculiarly branny condition of 
the scales seen in ringworm of the body. (The distinction between 
these disorders on the scalp is given elsewhere.) Lupus erythema¬ 
tosus is often symmetrical, generally chronic, and is characterized by 
the development of multiple, annular patches, enlarging centrifugally 
from a clearing centre. Herpes iris can be distinguished, first, by its 
predilection for the extremities; second, by the color variegations 
which it displays and which are never seen in ringworm of the hands. 
Syphilis is multiform in its lesions, usually preceded by a history of 
infection; and its distinctly circular patches, enlarging at the periph¬ 
ery, all exhibit either atrophic, ulcerative, or distinctly crusted symp¬ 
toms, which suffice for their recognition. 

Pityriasis maculata et circinata is not characterized by vesicles; is 


PARASITIC AFFECTIONS. 


727 


often symmetrical in development; occurs in oval rather than in dis¬ 
tinctly circular patches; and exhibits a characteristic tawny-yellowish 
shade of color not seen in ringworm. In eczema marginatum, the 
elevated border of the diseased surface, its situation (groins, armpits, 
pubes, etc.), its curved outlines, and the occurrence of fresh rings 
within the older, point to the nature of the trouble. . 

But the microscopical discovery of the parasite is the chief, and, 
indeed, the essential, method of diagnosis in tinea circinata. By the 
aid of a good fourth- or fifth-inch objective the spores and mycelium 
are readily recognized in the scales scraped from the affected surface 
and moistened with dilute liquor potassse. Duhring calls attention to 
the care which should be had in distinguishing the fungous elements 
from cotton- or wool-fibres, fat-globules derived from previously applied 
unguents for the cure of the disease, sebum, pus, and the nuclei of 
epithelia. All confusion of this sort can be avoided by a careful study 
of the anatomical peculiarities of the trichophyton, recalling especially 
the parallelism seen in the double contours of the threads, their jointed 
appearance, their contained granules, and the necklace-like or beaded 
arrangement of many spores. 

Treatment. The indication in the treatment of ringworm of the 
body is the removal of the superficial layers of the epidermis, by 
which means the spores and mycelium are thrown off from the surface, 
and, if possible, the simultaneous destruction of the latter. . Upon 
the delicate skins of infants and children the. simpler remedies are 
first to be employed. Scrubbing each patch with the spirit of green 
soap, or merely soap and water, will often suffice for its obliteration. 
The topical application of the tincture of iodin is a common and usu¬ 
ally an effective remedy. The same may be said of dilute acetic, 
boric, and carbolic acids. A solution of acetic acid used with or im¬ 
mediately before other parasiticides is said to favor the penetration ot 
the latter. Morris’s solution of thymol, 1 J drachm to 2 drachms 
(2.-8.) of chloroform and 6 drachms (24.) of olive oil, is equally 
available. One may also use thymol in ointments, | drachm (2.) to 
the ounce (32.) of simple unguent, with good effect. Of the mercu¬ 
rials, ammoniated mercury, 1 scruple (1.33) to the ounce (32.) ot oint¬ 
ment; corrosive sublimate, 1 to 2 grains (0.066-0.133) to the ounce 
(32.) of solution; and the ointment of mercurial nitrate, 1 drachm (4.) 
to the ounce (32.) of vaselin, are valuable. Sulphurous acid, from a 
freshly opened can, and saturated solutions of hyposulphite of sodium are 
as effective as any of the parasiticides, and are often used with advan¬ 
tage as lotions to be followed by an appropriate unguent, always pro¬ 
viding against chemical decomposition of the ingredients ot the latter. 
Sulphur- and tar-containing lotions and unguents are useful in more 

obstinate cases. . . e , 1A . , nQQ 

Chrysarobin and pyrogallol, in ointment, from 5 to 10 grains (U.«W- 
0.66) to the ounce (32.), are brilliantly effective in all these cases, 
subject, however, to the disadvantage incidental to the staining and 
irritative effects they produce. They should be used with caution 


Lancet, 1881, pp. 164 and 241. 


728 


DISEASES OF THE SKIN. 


upon the skins of children, and always tentatively at the onset. In 
cases of ringworm of the face of male adults, close to the beard or the 
scalp, one may employ these remedies with a view to insure the non¬ 
invasion of the pilary follicles by the fungus, the prompt destruction of 
which may become then a matter of urgency. Wilkinson’s ointment, 
recommended by Kaposi, is also useful in the treatment of aggravated 
forms of ringworm of the body, but it should be restricted to such 
forms. For other and more urgent reasons, caustic potash solutions 
should be reserved for exceedingly intractable cases. Sometimes a 
combination of several of the simpler remedies named above may be 


serviceable, as in the following 

formulae: 



R.—Lac. sulphur., 

3 ijss ; 

10 


Sapon. virid. spts., 1 
Lavandul. tr., / 

aa 3yj: 

24 


Glycerin., 

3ss; 

2 

M. 


[Kaposi.] 

R.—Iodin. pur., 


62 


01. picis [sp. gr. 0.853], 

Zj; 

32 


Mix with care, gradually. 




R.—Creosoti, 

TRxx; 

1 

33 

01. cadini, 


12 


Sulphuris praecip., 

fsfij; 

12 


Potass, bicarb., 


4 


Adipis, 

|j ; 

32 

M. 

To be used in obstinate ringworm of adults. 

[Van Harlingen.] 


R. W. Taylor applies bichlorid of mercury, 4 grains to the ounce, 
in tincture of myrrh. Perry, of California, uses the bichlorid in one- 
half the strength last named, dissolved in sulphuric ether. Foulis, of 
Edinburgh, recommends iodin dissolved in oil of turpentine or benzin, 
the fluids named penetrating with greater ease than others to the 
deeper portions of the skin. 

Other articles advised by authors are oleates of mercury and copper, 
croton oil, glacial acetic acid, cantharidal collodion, petroleum, and 
pyroligneous acid (Thomas). 

The thorough application of the remedy selected for use, upon the 
integument quite freed from its scales by scrubbing with soap and 
water, is a matter of some importance. When the solution of sodic 
hyposulphite is employed the previous application of dilute vinegar and 
water by sponging renders the agent more effective, for evident chem¬ 
ical reasons. Over-treated skins, or those to which too strong a para¬ 
siticide has been applied, require subsequent relief of the induced irri¬ 
tation by the simpler bland dressings. The inert dusting-powders, 
even when not thus indicated, are often useful when there is distinct 
vesiculation; and in simple cases they may be the sole remedies required, 
as then the disease is self-limited in duration. 

Liborius, having observed in China that the tincture of an unknown 
fibrous root was used successfully as a remedy for ringworm, obtained 
some of the plant, which was found to be the Rhinacanthus communis , 
the leaves of which, bruised and mixed with lime-juice, are used in 
India as an application for the same complaint. Liborius has since 



PARASITIC AFFECTIONS. 


729 


obtained from the root a quinin-like body, supposed to be the active 
constituent. It resembles chrysarobin in being antiseptic and anti- 
parasitic. He proposes to call it “ rhinacanthin,” and represents it 
by the formula C 14 H 18 0 4 . 

The internal treatment of patients affected with ringworm, by means 
of tonics and roborant measures, may be demanded by the systemic 
condition, but it has no recognized influence over the disease itself. 

When the nail is involved it should be thoroughly scraped and then 
kept moist by wearing over it the rubber cots sold in the shops for 
the use of sportsmen, fishermen, and others. In this way a partial 
maceration of the nail-substauce is secured, and the action of any one 
of the parasiticides named above, is greatly aided. One of the solu¬ 
tions most useful in the treatment of the nails is that recommended by 
Sabouraud, containing one gramme of iodin and two grammes of po- 
tasium iodid in a litre of distilled water. 

Prognosis. The disease is often self-limited, and is, generally, under 
the simplest treatment satisfactorily relieved. Eczema marginatum, 
especially in the crural region, may be obstinate, because it is an eczema 
as well as a parasitic disease, and, therefore, subject to the relapses and 
chronic phases of the first-named disorder. Other intractable forms 
of the malady do, however, occasionally occur in adults, usually in trop¬ 
ical climates and tropical temperatures. 


[B] Tinea Tonsurans. 

(Ringworm of the Scalp, Herpes Tonsurans, Tinea Tondens. 

Ger.j Scheerende Fleohte; Fr., Teigne Tondante.) 

Statistical frequency in America, 0.545. 

Tinea tonsurans is a cutaneous disease of the scalp, characterized by the occurrence 
of one or of several, circumscribed, non-elevated or tumid patches, over which 
the hairs are usually fractured at a point near the integument, producing thus the 
effect of partial baldness, while the scalp itself is the seat of vesiculation, scaling, 
or crusting, the disease being produced by the presence of the trichophyton, or of 
the “microsporon Audouini.” 

Ringworm of the scalp is a disease chiefly of children, and among 
the latter those resident in their own homes, but chiefly those congre¬ 
gated in public institutions for their care, education, and training. 
The gregarious habits of children and the frequency and intimate 
character of their contacts in their amusements and studies, greatly 
increase the chances of contagion when one of their number is affected 
with ringworm of the scalp. As a consequence, the early recognition 
and relief of the disease furnish problems among the most important 
presented to the general practitioner as well as to the dermatologist. 
Important considerations relating to the segregation, and, with that 
secured, the education of children, are wrapped up with the question 
of treatment. Nor should the physician, examining and giving advice 
about the scalp of a number of children, forget that his hands may 
transmit the disease to those as yet unaffected. 


730 


DISEASES OF THE SKIN. 


Symptoms. The differences to be particularly noted between ring¬ 
worm of the body and ringworm of the scalp depend largely upon the 
fact that in the latter the fungus makes its way to the hair-follicles, 
and there finds the nutriment for its multiplication and development. 

The disease begins at one or at several points by involvement^ of 
the hair-follicle, which becomes slightly tumid and reddened. The 
symptoms usually first observed are circumscribed, small coin-sized, 
roundish patches upon the scalp, wholly or partly covered by minute, 
whitish, slate-colored, grayish, or dirty-yellowish scales. Sometimes 
the formation of the scales can be observed as they develop upon a 
hyperemic and reddened area. Still more rarely, pin point-sized, 
transitory vesicles or pustules precede. The hairs upon such a patch 
seem irregularly clipped short near the surface or, as it is frequently 
styled, u nibbled ” off, thus producing the effect of partial baldness in 
the involved area. Among them may often be found lustreless, dry, 
long, and fragile hairs, which break upon slight traction or flexion. 
The patches may increase in number and spread individually in area 
until, in the course of weeks or months, the entire scalp is invaded. 
In the older patches, young and downy hairs may here and there be 
seen, pushing up the stumps left by those that have fallen. One or 
more of various phases of the disease may be presented in its subse¬ 
quent evolution. Thus, a single patch may extend to the size of that 
of a large coin or of the palm, and the disease be throughout limited 
to that area. Again, as just related, almost the entire scalp may be 
covered by relatively small or enlarging patches, or, even without the 
occurrence of any distinct patch, isolated hairs or tufts of hairs here 
and there over the entire scalp may exhibit evidence of impairment. 
The hairs, instead of “ starting” from the patch, may be twisted, 
imbricated, or matted together and be covered with grayish scales. 
The disease may be acute or be chronic in its course. Instead of 
assuming the dry and squamous type described, acute and exudative 
symptoms may develop, in which event the rare vesicular and pustular 
lesions are succeeded by the exudation of a gummy secretion and the 
formation of crusts. Lastly, there may be produced the variety known 
as “ kerion,” which is described below. 

Pruritus, in various grades of severity, though usually mild, is 
induced by the disease; and often the patches are altered in appearance 
by the traumatisms produced by the finger-nails and the comb. 
When the scalp is very generally invaded by the squamous form of 
the disorder, its appearance is very similar to that noted in diffuse 
seborrhea, chronic eczema, and psoriasis of the scalp, except that the 
hairs are less pasted to the surface; are more lustreless, friable, and 
contorted in shape; and much more often are represented by stubble 
or stumps. The disease may occur coincidently with ringworm of the 
body, and indeed at times there may be detected a ring, half of which 
on the neck presents the typical aspect of tinea circinata, and the other 
half involving the scalp exhibits the features here described. 

Stowers, 1 Sangster, 2 as also Hutchinson, Tay, Hillier, Baker, and 


1 Lancet, 1881, p. 326. 


2 Id., 1880, p. 303. 


PARASITIC AFFECTIONS. 


731 


others, have recorded cases in which the disease coexisted with alopecia 
areata. Geber asserts that after exfoliation of patches of ringworm the 
scalp may, in cases, become absolutely bald, smooth, and glossy, but that 
hair-stumps and scales in the environment indicate the nature of the 
disease, which is thus often mistaken for area celsi, or alopecia areata. 

This condition is the “ Bald Tinea Tonsurans” of Liveing, in which 
the smoothness and baldness of the scalp have produced the error that 
alopecia areata was present, an error readily corrected by the recogni¬ 
tion of scaling patches with hairs, exhibiting under the microscope 
evidences of the existence of the fungus. It is to be remembered that 
in all such persistent scaling patches left after treated or untreated 
ringworm of the scalp the possibility of contagion is not averted. 

The u Disseminated Ringworm,” of Alder Smith, is represented by 
individual pilary filaments, rather than by patches, where the disease 
is in insidious progress, a broken stump, or a group, or a relatively 
small number, of lustreless, dry, and friable hairs presenting the 
evidences of the disease. 

Sabouraud and others now claim that ringworm produced by the 
microsporon Adouini can be distinguished clinically from that produced 
by the trichophyton. In the former the patches are single or few in 
number, are rounded or oval in outline, may be of considerable size, 
are usually slightly reddened and furfuraceous, and are more or less 
covered with hairs which are lustreless, dirty-looking, broken off at 
irregular distances from the surface, and easily epilated between the 
thumb and finger in considerable numbers. Moreover, in this form, 
a grayish or whitish sheath (composed of spores) is seen encircling 
each hair and extending from one to three millimetres above its exit 
from the follicle. In patches of ringworm produced by the tricho¬ 
phyton, according to these observers, the patches are much more num¬ 
erous, but are very small, irregular in outline, and instead of being 
covered by hairs and broken stumps of hairs, usually show a number of 
black dots at the mouths of the follicles caused by the breaking of the 
hair at or beneath the surface of the skin. In this latter form of ring¬ 
worm the scalp itself is usually normal or nearly so, scaling not being 
usual, and, instead of forming patches, the disease may affect isolated 
hairs or small groups of the hairs. The “ Disseminated Ringworm ” 
and the “ Bald Tinea Tonsurans” mentioned above are probably 
produced by the trichophyton, and not by the small-spored fungus. 
It is undoubtedly true that the clinical differences mentioned above 
can be noted in some cases, and the diagnosis made at. once from a 
simple inspection of the affected areas. In the majority of cases, 
however, the clinical features are not so sharply marked, and the diag¬ 
nosis must rest upon microscopical examination or even upon culture- 

experiments. . 

Lastly, it is to be noted that in tinea tonsurans at times the. efforts 
of nature are successful iu obtaining spontaneous relief. With the 
defluvium capillitii and exfoliating epidermal plates the fungus may 
finally be removed; the resulting alopecia be followed by a growth of 
healthy pilary filaments; and, even though years be required for this 
long process, in the end no trace of the disease be discernible. 


732 


DISEASES OF THE SKIN. 


Etiology. Ringworm of the scalp is produced by the fungus recog¬ 
nized in the etiology of tinea circinata, the trichophyton, or by the 
microsporon Adouini. 1 Ringworm is frequently observed in children 
of both sexes, especially in those gathered together in schools and public 
charities, where it may be spread very generally from one to another, 
and require months and years for its extermination. It is a highly con¬ 
tagious disease, but yet requires unquestionably a suitable soil for its 
development. White 2 calls attention to the fact that Avhen there is 
ringworm on the face of an adult, even of rebellious form, in the 
course of which the beard may extensively be affected, the scalp is 
usually spared. Ringworm in the scalp of the adult and the aged is, 
indeed, among the rarest of cutaneous accidents. Among the methods 
of transmission in children are the use upon the head of the unaffected, 
of brushes, combs, wearing-apparel, sponges, towels, etc., which have 
been employed upon persons exhibiting ringworm of the body or the 
head. It must be remembered that tinea circinata may transmit tinea 
tonsurans; and it is by tracing the course of the two forms of the dis¬ 
ease that the sources of contagion can be ascertained in any series of 
cases. The disease is one rather prevailing in the cities than in the 
country; and in this respect it also differs from favus. 

Pathology. The disease is produced in consequence of the invasion 
of the scalp and follicles, bulbs, and shafts of the hair, by the fungus 
already described. 


Fig. 94. 



Hair invaded by the trichophyton. 


Under the microscope the hairs themselves, in advanced cases, are 
seen to be greatly altered (Fig. 94.) The bulbs are distorted, mis¬ 
shapen, or withered, and often stuffed with spores which greatly pre¬ 
dominate over the mycelium. At times the base of the bulb will show 
a brush-like expansion, and in this respect resembles the free ends of 
the stumps of the hairs above, which have a jagged, bristle-like appear¬ 
ance, from the division of the shaft into many filaments between which 
spores in abundance are visible. The shaft, is often longitudinally 


1 See introductory paragraphs on ringworm. 


2 Loc. cit, 




PARASITIC AFFECTIONS. 


733 


split, where the parasitic growth has mechanically forced apart its 
elements, and its cuticle may be peeled off, or curled above and below 
away from the axis, with spores protruding at such points. Conidia can 
be discovered much further upward along the hair and distant from 
the scalp than in favus; often, indeed, upon its free surface. Occa¬ 
sionally a few mycelial threads may be recognized, either longitudinally 
or transversely arranged as regards the axis. It is probable, however, 
that the relative preponderance of spores and mycelium in these fila¬ 
ments is determined by the stadium of the disease in any given case. 
In the earlier stages of the affection the elongated threads may be dis¬ 
covered in larger quantity, and, as they interfere less with the integrity 
of the fibrous tissue, the hair may usually at these times be extracted 
from its follicle without fracture. Later, the threads disappear and 
the conidia are infiltrated throughout every portion of the shaft,which 
then breaks often upon the slightest traction. One unaccustomed to 
microscopical examinations with a view to the detection of the parasite 
should be careful not to mistake for these threads the delicate lines 
which traverse the surface of the shaft exposed to the objective, and 
which represent the edges of the cuticle of the hair. In doubtful 
cases the hairs should be examined in liquor potassse aud after staining 
by the methods given in the first pages devoted to the subject of ring¬ 
worm. The scales found upon the affected scalp also exhibit traces of 
the trichophyton under the microscope, though to a less extent than 
the invaded hairs. In exceptional cases, however, the epidermis of the 
scalp seems to suffer as much as that of the non-hairy portions of the 
body. 

As to the mode of invasion, it is still disputed whether the spores 
find access to the fundus of the follicle between the shaft and the 
follicular wall, or by penetrating the cuticle of the hair-shaft at the 
level of the epidermis. It is possible that invasion may occur in both 
ways. 

Diagnosis. The recognition of a typical patch of ringworm of the 
head is simple. The branny scales, clumps of hairs, and distinct con¬ 
tour of the invaded area are always in the highest degree suspicious 
symptoms. It has been stated, however, that the general development 
of tinea tonsurans over the scalp produces a condition very like that 
seen in other diseases. In this case the microscope must be em¬ 
ployed for a decision as to the nature of the process. The whole vertex 
has been unnecessarily epilated in seborrhea sicca, when no parasite 
could be found; but in seborrhea there is usually a symmetry of 
involvement which even aggravated cases of ringworm of the head 
fail to assume; and even though pasted down, atrophied, changed in 
color, and loosened in their follicles, the hairs are rarely broken off 
near the scalp in seborrhea. In seborrhea, psoriasis, and squamous 
eczema of the scalp, there is, moreover, no history of contagion; the 
scales are in each disease different in color and character; and the hairs 
in the two affections last named are firmly fixed in their follicles, and 
only in severe cases present nutritional changes. The diseases, more¬ 
over, are usually chronic in their course. In any doubtful case, apart 
from microscopical evidence, thorough removal of all scales from the 


734 


DISEASES OF THE SKIN. 


scalp by shampooing with green soap and hot water will reveal the 
nature of the disease present. 

Alopecia areata, as has been noted above, may coexist with. ring¬ 
worm, but it is pathologically distinct from it. The patches in the 
first-named disease are uniformly smooth, and the hair falls from them 
en masse , without lesions, stumps, or other traces of previous involve¬ 
ment of the regions affected. Blackish points or dots may, however, 
be distributed over the areas which characterize this form of alopecia, 
and which certainly constitute suspicious symptoms in any case. In 
this event one may at times be able to pick out with a fine needle this 
blackish point from the patent follicular orifice, and find it to be a 
particle of dust accidentally lodged in the depression. It is not, as 
in comedo, free pigment which has found its way to the surface; nor, 
as in ringworm, is it the stump of a hair on a level with the surface 
of the scalp. In favus the cup-shaped crust will sooner or later 
betray the character of the disease to the naked eye. 

Confirmatory evidence as to the nature of the disease will often be 
furnished by a careful search for the source from which it was 
derived; and for obvious reasons this should always be attempted. 
Ringworm of the body occurring upon the individual patient affected 
with tinea tonsurans, or other members of the same household, and 
suspicious “ mangy ” patches upon horses, dogs, cats, rabbits, white 
mice, or other animals with which the child may have been in contact, 
should always receive attention. 

Treatment. The indication for the relief of the disease is the 
destruction of the parasite; and there can be no question that this 
may be accomplished in some cases without having recourse to epila- 
tiou. The parasiticides named in connection with ringworm of the 
body, if thoroughly applied in simple cases, after clipping or shaving 
the hair and an efficient scrubbing of the patch with spirit of green 
soap and water, will occasionally be followed by permanent relief. 
Prominent among these parasiticides may be named pyroligneous acid, 
sulphurous, acetic, salicylic, and boric acids, saturated solutions of 
sodic hyposulphite, acetum cantharidis, tincture of iodin; Crocker’s 
ointment containing thymol, one part to four; Morris’s solution of 
thymol in chloroform and olive oil (see Tinea circinata); and ointments 
of boric acid and sulphur, of each 1 drachm (4.) to the ounce (32.) of 
vaselin, and chrysarobin, the action of the latter being carefully limited 
to the patch of disease by the aid of a skull-cap. 

Epilation, however, is a valuable, and often an essential, method 
of treating the disease, and it may be practised as already recom¬ 
mended in considering the treatment of favus. The scalp in each 
case should first be oiled, and be cleansed by the soap shampoo, 
and, after the epilation is performed, an appropriate parasiticide should 
be employed. The calotte, made by spreading pitch-plaster upon 
leather or muslin, is a brutal substitute for epilation in order to remove 
the hairs, but the sticks recommended by Bulkley may be employed, 
the formula for the preparation of which has already been given. In 
each case the epilation should remove a zone of sound hairs encircling 
the diseased patch, that the encroachments of the fungus may in every 


PARASITIC AFFECTIONS. 


735 


possible way be limited. It should not be forgotten, however, in the 
treatment of tinea tonsurans by both epilation and parasiticides, that 
in chronic cases these methods, in the hands of the most expert, have 
failed for consecutive months to relieve radically the disease; that even 
the most inveterate cases, in the course of time and as adult years are 
reached, are spontaneously relieved without permanent alopecia; and 
that no remedy or procedure is ever justifiable which is capable of 
either producing follicular atrophy or an effect worse than that wrought 
by the disease itself. 

Coster’s paste is popular among English practitioners, including 
Stowers, Fox, Liveing, and others. It contains 2 drachms (8.) 
of iodin in crystals, slowly dissolved in oil of tar; and is painted 
over the part at intervals of a few days. It is most useful in cir¬ 
cumscribed patches of the disease. Among other remedies employed, 
some of which have been described in connection with ringworm of 
the body, may be named corrosive chlorid, ammonio-chlorid, red- 
oxid, oleate, and ointment of the nitrate of mercury; epispastics; pure 
carbolic acid and carbolated glycerin; sulphur, chloroform, ether, and 
tar in ointment, and, perhaps superior to all, Wilkinson salve. 

To be effectual the treatment pursued must be persistent and thor¬ 
ough, and always be accompanied by frequent washings and soapings 
of the affected part. 

The induction of suppuration in the hair-follicles (or a species of 
artificial kerion), by the aid of electrolysis and croton-oil liniment, has 
beeu praised by Alder Smith and Wyndham Cottle, of London, and 
later, in a modified form, by Magee Finny, of Dublin. By the pro¬ 
cess of Finny, one hundred parts of the oil are mixed with fifty each 
of cocoa-butter and white wax. Sticks are made of this compound 
which can thoroughly be rubbed into the part affected. By both 
methods, it is claimed that no pain is produced, nor is permanent alo¬ 
pecia the result. A solution of salicylic acid is applied after each 
treatment, and a subsequent poultice may also be needed. In these 
cases the parasite is presumably destroyed by the suppuration excited. 
As in the case of ringworm of the body, tinea tonsurans is not reme¬ 
diable by internal treatment. Such internal medication, however, may 
be indicated by the systemic condition of the little patients, and should 
he in each instance such as that condition suggests.. 

Prognosis . The ultimate prognosis in every judiciously treated case 
of tinea tonsurans is favorable, since all patients ultimately recover 
from the disease per se. Under the best treatment many cases prove 
extraordinarily tedious, month after month passing without marked 
improvement. The disease, however, in a large proportion of cases 
among children surrounded by proper hygienic conditions, especially 
as regards cleanliness, is readily relieved. 

Tinea Kerion. The occurrence of active and usually circumscribed 
inflammation in a portion of the scalp affected with ringworm is at times 
followed by certain peculiar features, the assemblage of which has been 
designated by the term tinea kerion. This complication of ringworm 
was recognized early in the history of medicine by Celsus, whose name 


736 


DISEASES OF THE SKIN. 


has since been associated with its lesions (Kerion Celsi, from xvjptov, 
a honev-comb). Tilbury Fox, in 1866, was first to recognize its iden¬ 
tity with tinea tonsurans; and it has since been the subject of a num¬ 
ber of interesting papers by Tanturri, Maiocchi, Schilling, Barduzzi, 
Auspitz, and Wilson. In the United States, Atkinson 1 has made it 
the subject of a valuable memoir. 

The symptoms are the occurrence of acute inflammation, usually cir¬ 
cumscribed, though occasionally diffuse, in a portion of the scalp where 
a tumor forms which may project to a considerable distance above the 
general level. In time the appearance presented is quite suggestive 
of anthrax benigna, since from tumid orifices of numerous distended 
follicles a viscid, semitransparent, and puriform fluid exudes. The 
latter is highly characteristic. The hairs loosen and fall. When the 
view of the lesion is not obscured by the pilary growth it appears as 
a flattened hen’s-egg- to turkey’s-egg-sized, boggy, semiglobular 
tumor, its surface congested, reddened, glazed, and often exhibiting 
other evidences of inflammation, with split-pea-sized, pustule-like 
lesions distributed over its surface, or, when these have ruptured, 
exhibiting the gaping apertures described above, from which a 
gummy secretion is poured in varying quantities. Modifications of 
this condition occur, such as the production of a true subcutaneous 
abscess with fistulous sinuses. The sensations awakened are usually 
painful; the course of the disease is chronic. It may begin with the 
usual symptoms of ringworm of the head, though often there is no 
history of the latter. The complication is a rare one. 

The parasite may and may not be found in patches of kerion, accord¬ 
ing to the acuity of the present or the precedent inflammatory process. 
If the latter be of high grade, and suppuration result, the fungus is 
destroyed, a result the attainment of which has been attempted in the 
production of an “ artifical kerion ” by means of croton oil for the relief 
of tinea tonsurans. In the earlier stages well described by Atkinson 
and represented by merely deep-seated follicular inflammation, with 
pustular development about the hair-shafts, the latter may be seen 
microscopically to be invaded with spores. 

The treatment is either by the milder parasiticides or by the methods 
proper for the relief of ordinary phlegmonous inflammation of the 
scalp, according to the stage of the kerion. The pus-cocci present in 
some of these cases require boric-acid lotions and bichlorid washes. 


1 Archives of Dermatology, January, 1881, vol. vii., No. 1. 


PARASITIC AFFECTIONS. 


737 


[C] Tinea Sycosis; Hyphogenous Sycosis. 

(Tinea Barbie, Sycosis Parasitica, Mentagra Parasitica, 
Ringworm of the Beard, “ Barber’s Itch.” Ger ., Para- 
sit are Bartfinne; Fr ., Trichophytie Sycosique.) 

Statistical frequency in America, 0.295. 

Tinea sycosis is a contagious disease of the region covered by the beard of the adult 
male, in which the integument, hairs, hair-follicles, and subcutaneous tissues may 
be involved, and which is characterized by the occurrence of macular, papular, 
vesicular, pustular, or tubercular lesions, owing to the presence of the trichophyton. 

Symptoms. The disease is best studied at its onset, in the beard of 
a blonde subject with relatively fine downy hairs, where are presented 
the typical features of tinea circinata, ringworm of the body. One 
or several, reddish, pea- to small coin-sized rings become visible, with 
pin-point-sized vesicles, branny scales, and often, indeed, no other 
lesion save a hyperemic, scarcely elevated margin at the periphery. 
The hairs over the patch may be fragile, and clusters here and there 
betray evidences of change. With proper treatment the disorder may 
not progress beyond this point. 

In some cases the very slight degree of itching awakened by the 
process just described may be intensified, and large plaques form, a 
portion of which may extend from the region of the beard over the 
face and neck, or vice versa. When fully developed, a phlegmonous dis¬ 
order is produced which bears some analogy to the kerion just de¬ 
scribed, and which may so actively progress that it is first seen in 
typical development. The skin is congested and reddened, with sub- 
epidermic (or debris of ruptured) pustules at the orifice of the pilary 
follicles, and is studded irregularly with firm, pea- to nut-sized papules 
and tubercles. The tubercles are usually aggregated in masses or lumps 
which involve the skin and subcutaneous tissue, and they are firm, 
often tender and painful, rarely boggy and furuncular. When pierced 
they give exit to a characteristic, muciform, gluey, yellowish, and 
sticky fluid, puriform yet differing from pure pus, that rapidly dries 
into crusts. These composite lesions are usually circumscribed in a 
given area of involvement, very rarely covering the region of the 
beard in symmetrical disposition, more often limited to one cheek, or 
to the cheek and chin. Duhring has an admirable portrait of this 
disease in his Atlas. 

The hairs in the invaded region are involved as in ringworm of the 
scalp. These filaments break near the surface of the integument, 
leaving ragged stumps; or they spontaneously fall after being loosened 
in their follicles. The ease with which they may be epilated is really 
one of the most characteristic features of the disease; they are slipped out 
of their follicles as readily as if they had been oiled; or, as Anderson 
writes “ as easily as a pin can be pulled out of a pin-cushion.” They 
are then often whitish because enveloped in the fungus producing the 
disease. In either event the resulting, gradual thinning, or removal 
of the hairs renders the disease of the surface more conspicuous and 

47 


738 


DISEASES OF THE SKIN. 


deforming. At the edge of a patch thus exposed, deformed, lustreless, 
contorted, flattened, twisted, or split hairs may be found. Occasion¬ 
ally the features of the patch are changed in consequence of the unusual 
degree of suppuration excited. In this case the pustules burst and 
their contents concrete into dry crusts about the stumps of shafts of 
surviving hairs, from which circumstance the disease has received its 
name (sycosis, aoxov , a fig). Rarely, a conglomerate crust covers the 
entire region with an excoriated, inflamed, and secreting surface beneath. 

Formidable cases of tinea sycosis occur in the persons of farmers 
resident in the extreme western part of the United States, where the 
disease is often long untreated and unrecognized. A few severe cases 
are produced after shearing sheep having diseased pelts. In these 
cases the cheeks, lips, and chin are the seat of nut- to fist-sized and 
larger cutaneous and subcutaneous, soft, boggy, and pus-filled tumors, 
accompanied by excessive soreness of the entire throat and neck, the 
hair falling from the follicles in large masses, and as if lubricated to 
facilitate their escape. 


Fig. 95. 



Filaments and spores of the trichophyton from the beard of a patient affected 
with tinea sycosis. 

Etiology. The disease is always produced by the trichophyton . 1 
White, of Boston, has called special attention to the frequency of its 
origin in the barber-shop, a fact which common experience verifies. It 
is usually the irregular visitor to these establishments who is first to 
supply the germs of the disease. No individual proprietorship in cup, 
soap, brushes, and razor can secure against the danger of infection the 
person whose razor is drawn over a common strop, whose cheek is 
handled by unwashed fingers which have recently been passed over an 
infected face, or whose beard is combed, brushed, or rubbed by the 


1 See introductory paragraph on Ringworm. 




PARASITIC AFFECTIONS. 


739 


implements and towels in common use at these establishments. The 
remedy is twofold: first, the full beard should be worn without shav¬ 
ing, as it is rare to find bearded patients of this class affected with 
tinea sycosis; second, where the whole or any part of the beard is to 
be removed, every adult male should learn to shave himself. The 
physician should, in this connection, for medico-legal reasons be upon 
his guard against hastily deciding both as to the nature of the disease of 
his patient and the source from which it was derived. Of the first, he 
can become certain by his microscopical investigations; of the second, 
he can only be sure by obtaining possession of facts far beyond the 
reach of the average practitioner. A medical gentleman once sent for 
examination some hairs from the beard of a male patient affected with 
tinea sycosis. Before receiving a report confirming the diagnosis, this 
physician was sued by the barber in whose establishment the disease 
had been probably acquired, on the ground of libel. 

It is difficult to determine the frequency of the disease from statistics. 
The affection is certainly relatively rare, yet more common than is fre¬ 
quently supposed to be the case. It is of somewhat irregular occur¬ 
rence, months often passing without a single case coming under obser¬ 
vation, after which several may be noted in rapid succession. 

The disease, being contagious, is one affecting men in all stations of 
life, and these usually at a period rather under than over the fortieth 
year. More men with light hair and eyes, and light brown, red¬ 
dish, or sandy beard are affected than those having darker shades of 
hair and eyes. Morris has called attention to the fact that tinea ton¬ 
surans 1 occurs more frequently in blonde than in brunette subjects. 

Pathology. The disease is essentially a follicular and perifollicular 
inflammation, induced by the irritative effects of the fungus, precisely 
as in the case of tinea tonsurans. The difference between the clinical 
aspects of the two diseases may in part be explained by the habitual 
covering of the scalp with caps and hats, while the face is left exposed; 
and by the occurrence of tinea sycosis in adult years, while tinea ton¬ 
surans is emphatically a disease of childhood. As a result of the 
induced inflammation, vesicles, pustules, papules, and tubercles aie 
formed, while the perifollicular inflammation may invade all portions 
of the skin and subcutaneous tissues, gluing together the plastic nod¬ 
ules formed about the individual hair-sacs, into the lumpy masses 
characteristic of the disease. The invasion of the hair-follicles and 
hairs by the fungus is accomplished as in the case of ringworm of the 
scalp. Under the microscope spores and myceliuna are visible, the 
former preponderating at the time when the disease first comes undei 
observation, but probably preceded in most cases by abundance of 
thread-like forms. The identity of the disease with some forms of 
ringworm of the body and scalp does not, however, rest merely upon 
microscopical observation, but is demonstrable by established clinical 
facts. Not only may ringworm be seen to spread from the face to the 
beard but tinea tonsurans and tinea circinata may also transmit tinea 
sycosis, and the reverse. A physician had ringworm of the bearded 

i Lancet, 1881, pp. 164 and 241. 


740 


DISEASES OF THE SKIN. 


chin and cheek derived from the face of a little patient under his care. 
He subsequently gave tinea circinata to his wife, who suffered on the 
face and shoulder, and she, in turn, communicated tinea tonsurans to 
her daughter . 1 

Diagnosis . The distinction between coccogenous and hyphogenous 
sycosis is of chief importance in this connection; and, necessarily, the 
microscope must be employed to settle the question definitely. The 
diseases, however, differ in their clinical features. The coccogenous 
form always fails to exhibit the nodules, tubercles, and composite cuta¬ 
neous and subcutaneous agglutinations of the disease produced by the 
fungus. The process in the former is more superficial, and it exhibits 
to the eye a more vivid redness as a result of the cutaneous hyperemia. 
Owing to the same cause, the frequent pus-containing lesions are devel¬ 
oped and elevated above the general level of the integument; they are 
less commonly subepidermic crypts filled with characteristic mucoid 
puriform contents. The region of the bearded upper lip, so often 
involved in cases of chronic nasal catarrh with coryza, is apt to be 
spared by the trichophyton. When this parasite is present the hairs 
are characteristically loosened, distorted, and otherwise changed. This 
condition is not seen in the coccogenous disease; exception, however, 
in this particular is to be noted in some long-standing cases of the 
latter. When the affection has persisted for many years (and one may 
often see patients thus affected) the thinned and starved condition of 
the pilary growth is a striking symptom, the scanty lustreless hairs often 
scarcely sufficing to conceal the deforming redness and pustulation of 
the surface from which they spring. The diffuse symmetrical affec¬ 
tion of the hairy face, extending over both cheeks and chin, is more 
frequently connected with the presence of pus-cocci. Lastly, the hy¬ 
phogenous, as a rule, is less painful and tender than the other form 
of sycosis, and is, without question, furthermore, of much rarer occur¬ 
rence. 

With respect to syphilis, it is to be noted that the papular or the 
pustular syphiloderm developed in the beard is, almost without excep¬ 
tion, to be discovered in other parts of the body, especially the scalp. 
Ringworm of the scalp and the beard, existing at the same time in one 
individual, is very rare. In syphilis there is usually an offensive odor 
to the abundant crusts; shallow ulcers are also apt to form beneath 
the pustules; and there is often a history of infection or a hint of the 
nature of the disease in its polymorphic character. 

Eczema of the bearded region may extend to or from other portions 
of the face, as in the case where it sweeps down from the ear above. 
The presence of a stalactitic crust, depending from the lobe of the ear 
of an affected side, would at once furnish a clue to the nature of the 
disease in the beard. In eczema the interfollicular region is invaded, 
not deeply, as in tinea, but superficially, as in coccogenous sycosis. 
The itching is severe; the hairs are not involved; the infiltration is 
diffuse; the outline is indeterminate; and a halo of redness spreads 
from the affected part to the non-hairy surface in the vicinity. 


1 See introductory paragraphs on Ringworm. 


PARASITIC AFFECTIONS. 


741 


Treatment. The treatment of tinea sycosis is generally conducted 
as in tinea tonsurans. It is customary to begin by anointing the 
affected surface with an oily or fatty substance, and to follow this with 
a shampoo of soap and warm water for the removal of crusts, after 
which shaving and epilation are practised on alternate days; and para¬ 
siticides employed locally. For softening the crusts the spray of the 
atomizer may be used. 

Epilation of the male beard is often essential for the removal of the 
disease, but the results of the treatment suggested below may in the 
end be satisfactory. It is true that a month or more may be required 
for the removal of the disease, but that is often the period of time 
during which treatment by epilation must be pursued. 

The patient for two successive days keeps the affected part macerated 
with almond or olive oil. On the evening of the third day the sham¬ 
poo with soap is employed, and the skin is washed free from all crusts 
and scales. The part is then cleanly shaved. The first is more pain¬ 
ful than any subsequent similar operation. After the shaving the 
affected surface is bathed for ten minutes in borated water as hot as 
can be tolerated, by which means the inflammatory condition of the 
perifollicular tissues is, in a brief time, considerably reduced. While 
the bathing is in progress all subepidermic pustules or points, where 
a mucoid fluid is coming to the surface, are opened with a fine needle. 
A solution of the hyposulphite of sodium is then sponged freely over 
the affected surface for several minutes; this solution may contain 1 
drachm (4.) to the ounce (32.) or even more. After a thorough and 
final washing with hot water, the tender skin is carefully dried and 
gently smeared with a sulphur ointment, containing 1 to 2 drachms 
of sulphur (4.-8.) to the ounce (32.) of vaselin, often with the addi¬ 
tion of from \ to \ (0.016-0.033) grain of red sulphuret of mercury. 
The patient then^ retires to bed. In the morning the unguent is 
washed off with soap and water, the sodium solution is reapplied, and 
a borated or a salicylated powder is thoroughly dusted and kept over 
the part during the day. In the evening the shaving may be repeated 
or not, according to the vigor with which the beard is reproduced, but 
on the second day shaving is imperative. As soon as the pustulation 
ceases and the tubercles have manifestly diminished in size, the oint¬ 
ment at night is superseded by the use, at that time also, of the dust¬ 
ing-powder. Whether the shaving is practised nightly or on alternate 
nights, ablution with very hot water and with the solution of the 
hyposulphite of sodium is continued nightly until the inflammation 
excited by the fungus is practically limited to the follicles which are 
invaded. The dusting-powder is to be thoroughly and constantly 
employed after the ointment is discontinued. With care and patience 
these measures may save many patients from the annoyance of epila¬ 
tion ; and they should be continued for several weeks after apparent 
relief of the disease. 

The treatment may be varied to suit the needs of individual cases. 
Kaposi highly recommends, for example, 1 per cent, solutions of cor¬ 
rosive sublimate locally; and the other parasiticides considered hereto¬ 
fore in connection with the treatment of ringworm may serve also 


742 


DISEASES OF THE SKIN. 


a good purpose. In some cases an ointment of thymol may be used 
with manifest advantage; in others, a substitute may be found in 
Morris’s solution of the same in chloroform and oil. The formula 
for this has already been given. In still other cases the stimulating 
spirit of green soap with sulphur, finely powdered sulphur, boric, acetic, 
and carbolic acids, or other topical applications of recognized value, 
may be employed. 

When resort is had to epilation, and this is essential in all severe 
cases, the hairs should be thoroughly removed from their follicles over 
every lumpy nodule, and even over every suspicious patch covered 
with scales. A zone should be cleared about each such papule. The 
results are prompt and in the highest degree satisfactory. 

Prognosis. This disease is always remedied sooner or later, though 
at times tedious in its progress and characterized by relapses. 

Precautions to be observed in the General Management 
of Tinea Favosa and Tinea Trichophytina. The physician con¬ 
sulted in the case of a patient affected with either of the diseases thus 
far considered as resulting from the presence of a vegetable parasite, 
should bear in mind that they are the most contagious of their class. 
He may not only himself suffer from the disease which he is attempt¬ 
ing to relieve in another, but may also convey it to others, or be 
consulted by others of his patient’s family, actually infected during the 
course of the treatment pursued. 

Generally, it may be said that the hands of the physician should 
carefully be washed after each manipulation of the part, and preferably 
bv aid of a weak disinfecting solution. In the case of children the 
lining of all caps, hoods, and other coverings of the head should be 
removed and destroyed by burning; and fresh linings made of tissue- 
paper renewed daily; while paper caps of the same or of similar mate¬ 
rial should be worn when indoors. Brushes, combs, towels, and arti¬ 
cles of clothing: should never be used in common by two or more 
individuals. When practicable, infected individuals should occupy 
separate beds; and the bed-covering, clothing, toilet apparatus, and 
dressing or other materials which have been in contact with a diseased 
surface should be immersed in boiling water before they are again 
employed for any use in common. Thin recommends covering every 
diseased patch, after the treatment appropriate to itself, with an adhe¬ 
sive and impermeable dressing, for the sake, not of the patient, but of 
those with whom the latter may be brought in contact; and the sug¬ 
gestion is both wise and practicable. A gentleman infected with ring¬ 
worm of the beard in a barber-shop which he has visited but once, 
will often, when directed by his physician to shave, resort to some 
other establishment, where he is well known, and where he has more 
confidence in the cleauliness of the operators. In this way he often 
thoughtlessly spreads the disease of which he is the victim. It is well 
to send patients who cannot shave themselves to a particular barber, 
who, being instructed in the manner of shaving so as to insure immu¬ 
nity, generally fails to spread the disease in any case 


PARASITIC AFFECTIONS. 


743 


TINEA IMBRICATA. 

(Tokelau Ringworm, Burmese Ringworm, Bowditch-island 
Ringworm, Lafa Tokelau, La Peta, Cascadoe, Gune, 
Herpes Desquamans. Ft Herpes Tonsurans Desqua- 

MATIF.) 

Tinea imbricata is a contagious disease, occurring chiefly in the tropics, character¬ 
ized by the formation of concentric and scaling annular patches produced by a 
vegetable parasite. 

This disorder was first described in 1844 by Fox, and has since 
been studied by Turner, Manson, MacGregor, and Roux. One ot the 
best clinical descriptions is given by Crocker. . 

Symptoms. The disease is first declared, after artificial inoculation, 
by a period of delay (“incubation”) lasting about nine days, alter 
which minute reddish points appear, arranged for the most part in 
semicircles, the former rapidly developing into papules producing an 
intolerable pruritus. The growth thenceforward is reported to be at 
the rate of from five to ten millimetres each week. In a brief time 
lamella; of epidermis are detached, their free border being directed to 
the centre of the circular disk, the patch or patches when fu y 
developed being represented by concentric rings, about five millimetres 
apart, suggesting a resemblance to “ watered silk. The scales may b 
as large square as half a centimetre, with curling edges which later 
become homy and much darker in color. It is said that the han 
passed over such patches from the circumference to the centre recog¬ 
nizes a smoothness of the surface, but when the motion is reversed, 
from centre to periphery, the scales are raised and resist the fingers. 
The appearance of the older patches suggests a skm covered with clay. 
The process of production of the concentric rings is reported to be, first 
by tile elevation of a central point of the epidermis and the formation 
there by the fungus of a brownish mass; then by separation of the 
epidermis at the central point, with persistence for a time of attach¬ 
ments at the border; then by liberation of the attached edge by friction 
or otherwise; and finally the exposure of the conum. Just beyond 
this line a brownish rim declares the line of advance of the fungus 
beneath the epidermis. When the ring thus formed has attained a 
diameter of about five millimetres, a brown point again appears cen- 
STy, and there is a repetition of the process originally observed in 

the An n po a rtmns n of the body may be affected; but the scalp and face 
seem tohe usually spared; when the hairy parts (scalp, pubes, axillae) 
are involved, the disease spares the follicles, and its management is 
thus declared to be correspondingly facile. Though the hairs the 
selves are not invaded, they are said to fall when the disease chances 
to extend over the hairy regions of the body. _ When the disease spon¬ 
taneously disappears from any portion of the integument there are left 
persistent, deep P -colored rings or circles where the scaling originally 
occurred. 


744 


DISEASES OF THE SKIN. 


Etiology. The disease is always produced by contagion; it occurs 
at all ages and in both sexes, especially in chidren; and is chiefly 
encountered in tropical climates. 

Pathology. According to Koniger (who was not a dermatologist) 
and Manson, the disease is produced by a special fungus, the tinea 
imbricata, which invades the epidermis without involving the hair- 
follicles, its oval or rectangular spores being more numerous than the 
mycelium, while the threads are long, straight, or gently curved. 
It is not yet determined that this parasite is not a development of the 
trichophyton peculiar to certain tropical regions; but Manson’s state¬ 
ment, that inoculation of the same individual with both tinea imbricata 
and tinea trichophytina produces each disease separately, seems toler¬ 
ably conclusive on this point. 

The diagnosis from “ Giant Ringworm,” “ Boatman’s Ringworm,” 
u Dhabie’s Itch,” u Majee’s Dad”—forms of trichophyton as it 
occurs in luxuriant vegetation upon the smooth portions of the body 
in tropical countries—is readily made. In these forms of ringworm 
the central area clears, while in tinea imbricata the central part of the 
patch is made up of concentric rings. 

Treatment. The scales are readily removed by soap and water or 
by alkaline baths, and chrysarobiu, pyrogallol, or iodin ointments are 
well rubbed into the part. In some cases strong lotions are employed 
of the same chemical constitution. 

The prognosis is favorable. 


MYCETOMA. 

(Gr. [ivKjjg, a fungus.) 

(Podelcoma, Madura Foot, Fungus Foot of India, Tuber¬ 
cular Disease of the Foot, Endemic Degeneration of 
the Bones of the Foot, Morbus Pedis Entophyticus, 
Ulcus Grave). 

Mycetoma is an endemic affection, due to the presence of a vegetable parasite in 
the tissues, affecting various regions of the body, but especially the foot and the 
hand, and when of long duration producing grave alterations in other organs 
than the skin, such as the muscular and osseous structures. 

From the date of the earliest description of this disorder by Eyre 
in 1806 to the present time a number of authors, chiefly Indian phy¬ 
sicians, have contributed to the literature of this disease. Among them 
may be named Brett (1840), Jille (1842), Ballingall (1855), Van Dyke 
Carter (1859), Berkeley and Biddie (1862), Hirsch (1863), Lewis and 
Cunningham (1875), and still more recently Layet, Liboroux, Bocarro, 
Bassini, Huntley, Surveyor, Boyce, G6my, Vincent, Kanthack, Adami, 
Kirkpatrick, and myself. 

The disease chiefly occurs in India, but is reported to have been 
observed also in China, Africa, Syria, and, in isolated cases, in a few 
countries of Europe. 










































































































































I 





















f 





























. 



























PLATE XU. 



DR . HYDES CASE OF MYCETOMA 


PARASITIC AFFECTIONS. 


745 


The record of its first recognition on the American Continent is 
embodied in the apparently unsupported statements of Ruelle, 1 who 
reports that Collas observed one case at La Reunion; Grail and 
Grand-Mourrel, each one case in Guiana; and Layet one in Chili and 
another in Valparaiso. McQuestin 2 saw three cases affecting native 
Mexicans in the Civil Hospital of Hermosillo, and Kemper 3 has 
reported a case which for some years has been thought to be the first 
occurring in the United States, but a critical examination of his 
description of the acute symptoms presented by his patient leaves the 
question of diagnosis somewhat unsettled. Dr. Lamb, of the Surgeon- 
General’s office in Washington, is reported to have recognized the dis¬ 
ease in a Mexican whose foot was amputated during the late Civil War 
in America. Dr. Charles T. Parkes reported that he had successfully 
operated upon a patient suffering from mycetoma in the city of Chi¬ 
cago. The disease had, however, been contracted in India. 

The first case, where no question exists as to the diagnosis, certainly 
known to have originated in North America, is that reported by Prof. 
Adami. 4 The subject was a French Canadian. Soon after the appear¬ 
ance of this report I published the record of an undoubted case of 
mycetoma 5 occurring in a native of Iowa who had never been outside 
of his native State before visiting the city of Chicago. The symptoms 
of the disease, as exhibited in the foot removed from this patient, are 
depicted on the accompanying plate. 

Symptomatology. There are supposed to be three varieties of myce¬ 
toma—the black, the white, and the red or ochroid—and some doubt 
exists as to whether all are produced by one fungus, seeing that no 
intermediate forms between the varieties thus distinguished have yet 
been recognized. The part chiefly affected in most of the Indian and 
in the American cases is the foot, and this chiefly of persons walking 
bare-footed; but the hand, the shoulder, the knee, the scrotum, and 
other regions have been attacked. As distinguished from the lesions 
of actinomycosis, it is noteworthy that the regions of the jaw and the 
neck are usually spared. 

In a typical case the foot is involved by progressive spread of the 
disease from the site of a trifling traumatism which often at first heals, 
and is followed later by the development near the site of the wound 
of a button or nodule which both increases slowly in volume and is 
later surrounded by similar lesions. The progress of the disease’is 
exceedingly chronic, as five, ten, and many more years have not rarely 
been recorded as required for its complete evolution. 

In fully developed cases, when the foot is involved, the organ is 
seen to be deformed by a large increase in volume, producing a bulg¬ 
ing of the parts posterior to the digits over the dorsum above, and 
below over the plantar region, giving the sole a convex appearance. 
Over the tumid parts the skin is beset with numerous pea- to nut¬ 
sized isolated nodules, elevated to the extent of several millimetres 


1 Contribution a l’etude du Mycetome, Bordeaux, 1893, p. 13 et seq. 

2 Pacific Med. and Surg. Journ., 1S73, pp. 652-555. 3 American Practitioner, 1876. 

4 Transactions of American Association of Physicians, 1895. 

5 a Contribution to the Study of Mycetoma, as it occurs in America. Journ. of Cutan. and 

Gen -Urinary Dis., January, 1896. 


746 


DISEASES OF THE SKIN. 


above the general level, each pierced with a fistulous channel extend¬ 
ing from that without to the deeper structures. At times these fistu¬ 
lous tracts lead only to the soft parts and especially to muscular tissues; 
at others the surface of the bone is reached and the osseous tissue is 
eroded by the growth of the parasite and the coccogenous infection 
which results from long exposure of the parts to the air. It is through 
these fistulous orifices that in different cases exit is given to a blackish 
fish-roe-like substance, or to a whitish material, or even still more 
rarely, as indicated above, to a reddish substance. 

In place of nodules or papules, the skin may be the seat of pustules, 
of vesicles, of bullae, or even of abscesses. When but relatively small 
regions of the body are invaded, such as a finger or a toe, it becomes 
clear that the tumefaction is not due chiefly to an hypertrophy either 
of the integument or the bones. 

Etiology. The disease, though of more common occurrence in India 
than elsewhere, may develop in other lands. The relatively fre¬ 
quent involvement of men is probably due to the greater exposures 
of the bare feet in persons of that sex. The disease is due without 
question to the access to the tissues of a special vegetable parasite, and, 
as far as is known, usually through the portal of a traumatism. 

Fig. 96. 



Osseous lesions in mycetoma. (From a photograph.) 


Pathology. The discovery of a fungus by Vandyke Carter (named 
from him the Chionyphe Carteri) and the later belief that the parasite 
of mycetoma was identical with that of actinomyces have been suc¬ 
ceeded by a series of investigations which show with clearness that 
actinomyces is related to but not identical with the fungus of mycetoma. 
Under the microscope the lobate-reniform masses constituting the 
“ grains” recognized in the last-named disorder are seen to be formed 


PARASITIC AFFECTIONS. 


747 


by a dense centrally placed mycelium with peripheral filaments which 
radiate very uniformly from within outward, and which may or may 
not terminate in “ clubs,” these last being probably the resultant of 
the interplay of force between the outspreading fungus on the one hand 
and the resisting power of the tissues on the other. 

In the three areas to be equally recognized on section of. the 
“ grains, ” the central exhibits delicate filamentous threads radially 
arranged; the marginal zone longer, more distinct, and somewhat more 
slender threads; while the radial zone, separated from the last by a 
narrow space, exhibits a few granular threads, but for the most part 
appears to be made up of a granular tissue. Outside of the fungus- 
mass are closely packed leucocytes, new-formed vessels having walls 
infiltrated with proliferating cells, and occasional giant cells. The 
bones when denuded of tissue are found to be honeycombed with finely 
carved seams, depressions, furrows, and pits, leaving delicate spicula 
of osseous tissue projecting between the excavations wrought by the 
growth of the parasite. It is possible to find, as Prof. Adami suggests 
in the careful study of his case, intrusive organisms, the result of expo¬ 
sure for so long a period of time of the deeper tissues to the atmos¬ 
phere. 

The fungus differs from that of actinomyces in that the former reacts 
indifferently to, while the rays of actinomyces are brilliantly colored 
by, acid fuchsin. 

Diagnosis. The disease in all cases of long standing is readily recog¬ 
nized by the characteristic deformity it produces, by the escape of fish- 
roe-like particles in the black variety, and in others by the discharge 
of the elements of the fungus, which can be determined by the micro¬ 
scope. The nodes or papules visible externally in all well-marked 
cases, each perforated with a sinus leading downward to the deeper 
structures, and the painlessness for the most part of the involved organ, 

are all characteristic. # , . 

As distinguished from actinomycosis, it is well to remember that m 
mvcetoma there is never any involvement of the viscera; the disease is 
exceedingly chronic; all systemic symptoms are absent; and the affec¬ 
tion is common in countries where actinomycosis is practically unknown. 

Treatment. The disease is radically treated by surgical ablation of 
the affected organ or by erasion of tissue. Even after progress ot the 
disease for many years the speedy recovery in cases so treated is sat¬ 
isfactory. 


ACTINOMYCOSIS OP THE SKIN. 

(Gr. auric, ray, and ftfncqg, mushroom ) 

(“Lumpy-jaw.” Ger., Aktinomykose; Fr., Actinomycose.) 

Actinomycosis is a parasitic disorder, occurring in man and in some of the lower 
animals, produced by the ray-fungus. 

This disease was first recognized in 1887 as due to a parasite which 
Harz described, from its gross appearances, as the “ ray-fungus, occur- 


748 


DISEASES OF THE SKIN. 


ring in the jaws of cattle. It has since been recognized in man, and 
still later, by Majocchi, as of occurrence in the skin. 

Symptoms. In actinomycosis this parasite usually effects entrance 
by the avenue of a carious tooth, and the skin when implicated is, 
as a rule, secondarily involved. Such skin lesions are more often 
displayed about the face and neck, more particularly the lateral sur¬ 
faces of the neck beneath the jaw, where deep subcutaneous tumors 
or swellings, livid in hue, thinning at one or at several points after 
involvement of the integument, finally burst and give exit to a sero- 
sanguineous or bloody and purulent fluid, containing yellowish masses 
in which the fungus may be recognized. The orifices of the sinus or 
sinuses after such discharge are usually beset with cutaneous and sub¬ 
cutaneous nodules and uneven lumps, some softened, others firm and 
indurated, usually reddish or purplish in hue, tender, painful, and 
often accompanied by pains elsewhere, particularly in mastication, in 
deglutition, and in certain movements of the head on the neck. 

The onset of the disease is insidious, and it is said to occupy in cases 
months and even years. The nearer to complete evolution of the dis¬ 
ease, the more rapid, as a rule, is the development of its symptoms. 
In exceptional cases the malady attacks the fingers, the hands, and 
other parts of the body. Pringle reported a case in which a large sur¬ 
face covering the lumbar region and thigh was secondarily affected 
after involvement of deeper organs. 1 

Etiology. As in mycetoma, more men than women are attacked as 
a result of special exposure; some of the affected have been occupied 
with cattle and horses; others having carious teeth may have been 
infected by accidents of contact or by the operations of dentistry. 
Murphy, of Chicago, had an interesting case of this disease in the 
person of a woman whose dog had died with a large swelling under 
the jaw. In most cases there have been submaxillary lesions and 
carious teeth. 

Pathology. The parasite, actinomyces , or “ ray-fungus,” is visible 
to the naked eye in the form of opaque, yellowish-white grains, at times 
sulphur-yellow or even greenish-yellow in color, pin-head- to split-pea¬ 
sized, which, floating in a serous fluid, suggest at first sight caseous 
pus from a tuberculous abscess. Examined microscopically, these 
grains are found to be made up of delicately interwoven threads, single 
or dichotomously divided, radiating from a common centre and club- 
shaped at the terminus. The bulbous knobs are supposed to be the 
sporules, and the rays to be mycelium of the fungus. The latter can 
be cultivated in nutrient media, with the result of producing the dis¬ 
ease in the lower animals after inoculation. 

Diagnosis. All supraclavicular and submaxillary lesions consti¬ 
tuted of dark-reddish tumors or swellings, subcutaneous in origin, 
should carefully be differentiated from actinomycosis. Scrofuloderma 
is to be recognized by the general condition of the patient (actino¬ 
mycosis may occur in vigorous young adults); by the absence of pro¬ 
nounced gumma and lymphoma (“gomme scrofuleuse”); and by 


1 Medico-Chirurgical Transactions, vol. lxxviii. 


PARASITIC AFFECTIONS. 


749 


failure of recognition of the parasite, which is not easy of detection. 
The occupation of the subject of the disease (as a farrier, stable-boy, or 
drover) may furnish a clue to the origin in some cases. Care should 
always be taken, in making a diagnosis, to exclude cases of swelliugs 
discharging pus, practically limited to the skin immediately over the 
lower jaw, with sinuses leading to the bone beneath, where the disorder 
is exclusively due to a carious fang of one of the lower central or canine 
teeth. All these may be relieved by the extraction of the offending 
tooth. 

The treatment has been until recently by surgical procedures, erasion, 
antisepsis by the bichlorid of mercury, boric acid, and dressings with 
antiseptic gauze. Gautier has employed with success an electro-chem¬ 
ical method of treatment, by the use of platinum needles and injections 
of a 10 per cent, potassie-iodid solution. Two needles are inserted, 
one connected with each pole of the battery, and a current of fifty 
milliampSres is passed; a few drops of the iodin solution are injected 
every moment during the flow of the electricity, the patient being 
anesthetized. Before attempting surgical measures the iodid of potas¬ 
sium given internally should be tried, since it has proved successful 
in a number of cases. Pringle’s extensive case, mentioned above, 
made a complete recovery after a few months’ course of the iodid. 
Morris reported a very interesting case in which, under the influence 
of the iodid, the fungus gradually disappeared and lost its character¬ 
istics. Other cases are reported in which recovery followed the 
administration of the iodid. 

Prognosis. It was held until lately that the prognosis was favor¬ 
able only in case of thorough and prompt removal of all diseased 
tissue. In other cases a fatal result was anticipated. 

Schlange, however, at the Congress of German Surgeons, held in 
1890, called attention to the fact that of nearly two hundred patients 
under his observation (over one-half traced since 1886), forty were 
completely cured for more than two years; and in eighty the disease 
remained limited to the head and neck. After thirteen years of 
involvement, one patient at the date of the report was alive. All 
extensive operations for relief of the malady are now abandoned. The 
iodid of potassium is certainly effective in some cases and is worthy 
of a trial in all. Even actinomycosis of the lungs and viscera is sus¬ 
ceptible of spontaneous recovery. Intestinal complications only are 
grave. Cases apparently hopeless have recovered in five and six 
years. 


750 


DISEASES OF THE SKIN. 


TINEA VERSICOLOR. 

(Pityriasis Versicolor, Derm atom ycosis Furfuracea, Mycosis 
Microsporina ; Chloasma. Ger ., Kleienflechte.) 

Statistical frequency in America, 1.02. 

Tinea versicolor is a cutaneous disease, occurring chiefly upon the trunk, neck, 
and upper extremities of adults, characterized by irregularly reticulated macular 
lesions, yellowish or brownish in hue, over which the epidermis may exfoliate in 
delicate scales, owing to the presence of the microsporon furfur. 


Symptoms. The eruption in this disorder occurs in the form of few 
or of many, irregular, roundish, circumscribed or reticulated macules, 
pin-head to small coin-sized, rarely occupying an area of the size of 
the palm or larger. In color it varies from the most delicate buff or 
fawn shade to a reddish, deep-brown, and even blackish hue. The 
surface of each lesion, when closely inspected, is usually seen to be 
covered by furfuraceous scales. If the scales are not visible, slight 
erasion with the finger-nail or the curette will demonstrate the fact 
that the superficial layers of the stratum corneum are, in the site of 
each lesion, readily separable from the tissues beneath. The eruption 
is most common upon the anterior surface of the thorax; but it is also 
displayed upon the neck, the dorsum, the abdomen, and the other re¬ 
gions of the trunk, and the flexor aspects of the upper extremities (the 
hands only excepted). It is rarely seen upon the lower extremities; 
still more rarely on the face; never on the hands and feet. The erup¬ 
tion is either unproductive of any sensation, or is accompanied by a 
mild pruritus. Patieuts usually declare that after profuse sweat¬ 
ing, bathing in warm water, or brisk friction of the surface, minute 
epidermal rolls separate from the affected area. The disease may 
linger for years upon the surface of the body. It has a special ten¬ 
dency in susceptible individuals to recur after removal. 

Exaggerated forms of the eruption are occasionally encountered. In 
a young married woman who had been the subject of the disease for 
many years, the entire trunk, the axillae, the groins, the upper portion 
of the thighs, the neck to the level of the high collar worn, and the 
upper extremities to the wrists, were encased in a uniform sheet or 
cuirass of chocolate-tinted epidermis, in a condition of exfoliation in 
finger-nail-sized lamellated flakes. Even in these extreme cases the 
tendency of the disease to avoid the surfaces exposed to the light is 
distinctly manifested. Unna 1 describes another anomalous feature of 
the disease, in which the maculations occur in annular form with a 
clearing centre. Rarely, also, a v§ry few irregularly distributed mac¬ 
ules may be seen as the sole evidences of the existence of the parasite. 
Thus, a patient may exhibit a small coin-sized patch on the surface of 
the chest, another on the shoulder, and possibly a third over the deltoid 
region of one arm. These are generally cases partially relieved of a 
more diffuse eruption. More commonly, the slightest manifestation 


1 Viertelj. f. Derm. u. Syph., 1880, Nos. 2 and 3. 


PARASITIC AFFECTIONS. 


751 


of the malady is an irregular, vertically arranged, somewhat narrow 
band of lesions immediately over the sternum, and visible beneath the 
hairs of that region in the adult male, or upon the intermammary 
sulcus of women. The face, hands, palms, soles, hairs, hair-follicles, 
and nails are usually exempt from the disease. 

Etiology. The disease is produced by a vegetable mould, discovered 
in 1846 by Eichstedt, to which Robin gave the name Microsporon 
furfur (Fig. 95). In capabilities for contagion it is far inferior to the 
vegetable parasites already described, and it illustrates well a point to 
which attention has been already directed, viz., that all these fungi 
flourish only in soils suitable for their germination and fructification. 
Members of one family are said to communicate the disease occasion¬ 
ally, the one to the other; and Lancereaux 1 reports that in this way he 
accidentally infected himself from scales collected for examination 
from a patient in hospital, and afterward unwittingly transmitted the 
affection to his wife. The disease occurs in both sexes, rarely before 
puberty and after middle life, and in persons of every social condition, 
irrespective of personal cleanliness. It is exceedingly common, more 
so, indeed, than statistics are capable of demonstrating, inasmuch 
as hundreds who are annually annoyed by it never seek professional 
advice. In physical examinations made with a view to the enlist¬ 
ment of men for military service, as also of government pensioners, 
the disease is often recognized upon the persons of those who pay no 
attention to its presence. Being concealed by the clothing and unpro¬ 
ductive of much discomfort, many subjects of tiuea versicolor endure 
its presence with complacency. 

By some it has been supposed that the fungus is particularly apt to 
select the chest of the phthisical as its habitat, a supposition doubtless 
based upon the fact that tuberculous men and women, more than all 
others, expose the chest to the view of the medical man in order to 
permit of its auscultation and percussion. 

Pathology. The microsporon furfur is readily recognized by the aid 
of the microscope, as it exists in luxuriant profusion upon every affected 
surface. The scales may be scraped from the skin, and at once be 
examined, when innumerable clustered spores and short threads become 
visible; the former highly refractive and resembling in their circular 
and oval contours droplets of oil. Their aggregation in clusters is dis¬ 
tinctive of this among the other forms of cryptogamic vegetation. They 
measure 0.0023 to 0.0084 mm., while the hyphae vary in diameter from 
0.0015 to 0.0038 (Duhring). Among the latter sporophores are dis¬ 
tinguishable, with'contained conidia and terminal elements emerging 
at one extremity or the other of the spore-case. Both elements are 
more readily stained by eosin and methyl-violet than those of the 
trichophyton or of favus. # . 

One of the strongest arguments against the claim for the identity 
of all the vegetable parasites is furnished by the history of this inter¬ 
esting mould. It never by auy possibility invades the hairs or the 
hair-follicles, though it may be seen flourishing at the orifice of a fol- 


i Traite d’Anatomie Pathol., xi. p. 265, Paris, 1875. 


752 


DISEASES OF THE SKIN. 


licular duct, and even beneath a vigorous pilary growth upon the 
chest of a male subject. It avoids the light and the air; and singu¬ 
larly refuses to encroach even upon certain covered portions of the 
body, preferring, in its extreme development, to linger unobtrusively 
at the neck near the verge of the collar. 

Diagnosis. In this disease, as in all parasitic affections of vege¬ 
table origin, the microscope may be required to decide the diagnosis in 
any case where doubt may arise. In its simpler manifestations, the 
recognition of the affection is readily assured. The location of the 
eruption, its irregular reticulations, its characteristic, yellowish or 
fawn-tinted shades of color due to the nature of the fungus, and the 
exfoliation of the epidermis which it excites by its superficial penetra¬ 
tion of the outer layer of the stratum corneum, producing thus a 


Fig. 97. 



mealy, branny, flaky, or roll-like exuvium, are all significant. None 
of the chloasmata due to pigment-changes in the skin, however much 
they may resemble tinea versicolor in color, share with it this peculi¬ 
arity of desquamation. Chloasma may involve, moreover, the face; 
tinea versicolor almost never. Vitiligo occurs upon the scalp; 
tinea versicolor very rarely. The macular syphiloderm may be mis¬ 
taken for the disease under consideration, but, when developed to such 
an extent as to rival tinea versicolor in its diffuseness, the syphiloderm 
will creep out over the face, the hands, and the feet and will be accom¬ 
panied by adenopathy, alopecia, mucous patches, palatine hyperemia, 
or will furnish evidence of a polymorphic tendency. Often, indeed, 
with such an eruption, the survival of the initial sclerosis will at once 
betray the nature of the disease. These are important considerations, 


PARASITIC AFFECTIONS. 


753 


since in the mere matter of subjective sensation, color, shape, and 
size of lesion, there may be marked resemblance between the two. 
Patients exhibiting the lesions of tinea versicolor may suffer from 
syphilis, and many having the former disease, in consequence of a 
suspicious exposure, believe they are infected with lues, and yet 
indeed are not. These incidents serve to illustrate the importance of 
making an accurate diagnosis in every case of cutaneous disease. 

The most vulgar error committed in this connection, however, is 
based upon the fancied resemblance in color between the patches of 
tinea versicolor and either the liver itself or the color-changes which 
disease of that viscus is capable of producing in the skin. The exist¬ 
ence of u liver-colored” spots in the skin is, hence, erroneously attrib¬ 
uted to hepatic disease. Few patients consult their physician for the 
relief of this disorder who have not a prejudice respecting the internal 
origin of the disease. 

Treatment. A single method of relieving tinea versicolor is recom¬ 
mended for the simple reason that it invariably is successful. It is 
practically that given by Tilbury Fox, and requires merely vigorous 
and intelligent co-operation on the part of the patient. A hot bath 
is taken, if possible, for three nights in succession, and when the 
surface is well macerated in hot water the affected skin is resolutely 
scrubbed, either with the cheap yellow soap of the shops, or with sapo 
viridis in substance or in tincture. When the disease is extensively 
developed, this process is aided by friction with a flesh-brush or with 
a coarse towel. The skin is then washed clean with a surplus of hot 
water, the patient still remaining in the bath, after which the affected 
patch is first moistened with vinegar and water, or dilute acetic acid, 
and afterward well sponged with a solution of sodium hyposulphite, 
1 drachm (4.) to the ounce (32.) being usually sufficient.. As a rule, 
the last vestiges of the eruption are removed with the third bathing. 
Should there be recrudescence in isolated patches, as is often the case, 
or outlying areas which have withstood the parasiticide employed, they 
should subsequently be attacked with a solution of corrosive chlorid 
of mercury, 1 to 2 grains (0.066-0.133) to the ounce (32.). Other 
measures, however, are popular with physicians, and among them may 
be named the topical use of boric, carbolic, or sulphurous acid; the 
tincture of iodin; sulphur in bath, ointment, or.lotion; calomel in 
ointment; the alkalies in bath or lotion; sulphid of potassium in 
bath; chrysarobin, pyrngallol, tar, Wilkinson’s salve, and the other 
parasiticides employed in the treatment of ringworm of the body. 
The inner clothing should not be worn after treatment, until it has 
been immersed in boiling water. 

The following formula is also recommended : 


ft —Hydrarg chlorid. corros., Bj; 

Saponis viridis, 3 U ; 

Spts. vin. rectif., 

01. lavandul., 5 


1 33 
64 
128 

4 M. 
[Anderson.] 


Prognosis. The disease can readily be relieved by simple treatment. 
Relapses often occur, and require to be radically treated. Untreated, 

48 


754 


DISEASES OF THE SKIN. 


the disease may continue for years without the slightest impairment of 
the general health. It is probable that when untreated the parasite 
undergoes spontaneous exfoliation in advanced years, a period when 
presumably the fungus fails to find in the epidermis the nutriment 
upon which it thrives. 


Myringomycosis. 

The spores of aspergi/lus, being conveyed to the external ear, occa¬ 
sionally develop there, especially if they come in contact with fatty 
substances introduced for medicinal purposes. There can then be 
recognized in the canal whitish masses, covered with greenish, brown¬ 
ish, or blackish spots. There is usually some deafness, with a sensa¬ 
tion of ringing in the ears, and at times a thin serous discharge from 
the external auditory meatus. Lowenberg 1 recommends the injection 
of dilute alcohol into the canal for the destruction of the mould. 


ERYTHRASMA. 

(Gr. epvflpdg, red.) 

Erythrasma is a cutaneous disorder, affecting chiefly those regions of the body where 
the surfaces of the skin are in contact, characterized by ^erythematous, rosette- 
shaped maculations, and due to the presence of the microsporon minutissimum. 

Burckhardt first described this disorder in 1869, but it received its 
name in 1862 from Von Biirensprung. It has since been carefully 
studied and described by Balzer, Riehl, Koebner, Pick, and others. 

Symptoms. The disease first appears in punctiform to palm-sized, 
roundish, definitely circumscribed maculations, presenting a sharp con¬ 
trast in color with that of the adjacent integument. This hue varies 
somewhat according to the location of the patches. The younger 
lesions may exhibit a vivid redness over the entire macules, or over 
their borders only. The older lesions exhibit a yellowish or a brown¬ 
ish tinge. These colors are compounds of ordinary erythematous red¬ 
ness and yellowish or brownish discoloration of the horny layer of the 
•epidermis. 

The macules are circular or rosette-shaped, or they display very 
irregular outlines. They are not raised to any extent above the general 
level of the skin, though the finger passed over the surface can recog¬ 
nize a slight elevation of the border, due to hyperemia, and subsequent 
moderate, fine flour-like, furfuraceous desquamation, most conspicuous 
also at the periphery. Vesiculatiou and papulation do not occur. The 
colors recognized in different patches may be light reddish-brown, pale 
reddish-yellow, and light or dark orange. 

The eruption is most commonly encountered where apposed surfaces 
of the skin come in contact, such as in the axillae, the groins, the cleft 
of the anus, and the regions where the scrotum touches the thigh. It 


1 Gaz. hebd. de Med. de Paris, 1880, 2me ser. xvii. p. 579 


PARASITIC AFFECTIONS. 


755 


occurs, however, in typical expression on both sides of the chest. The 
eruption spreads very slowly and in serpiginous outline until the affected 
surfaces are completely invaded. It is much more chronic in its course 
than the other dermato-mycoses, lasting for months and years without 
apparent change. 

Ftg. 98. 



Microsporon minutissimum, from patches ot erythrasma. 


Etiology. Erythrasma is produced by the growth, in the superficial 
layers of the epidermis, of the fungus described below. Men are much 
more often affected than women; children not at all. The youngest 
patient whose case is recorded was sixteen years old; the oldest, fifty- 

five. . . /T ,. 

Pathology. The fungus termed microsporon minutissimum (* lg. Joj, 
to which the disease is attributed, is chiefly remarkable for the extra¬ 
ordinary delicacy and fineness of its threads and its very minute spores. 
The threads are either simple cylindrical bodies of variable size, or they 
may exhibit partition-septa; they may divide dichotomously, and may 
terminate in hooked or knobbed expansions. They are inextricab y 
interwoven when occurring in large masses. The largest transverse 
diameter is 0.6 of a micromillimetre; in length the mycelium presents 
the greatest variation. Bacteria and heaps of zooglea are visible among 
the scales. The granules are piled into irregular heaps, according to 
Burckhardt, aud they give a dusty appearance to the epidermal cells 
on which they lie; often the outline of these granules is indistinct. 
According to" the same observer, the breadth of the hyphse is 
mm.; and the length from y 1 ^ to yj-y mm. . . 

Pasquale de Michele 1 discovered the leptothrix in cases of supposed 
erythrasma; and this is but another of the proofs that in all diseases of 
this class, as in so-called “ eczema marginatum,” there are few instances 


i Annal. de Derm, et de Sypb., 1891, p. 776. 



756 


DISEASES OF THE SKIN . 


in which a single monld-fungus develops on the body-surface. The 
entire flora dermatologica of Unna may be effective in more cases than 
is commonly estimated. 

Diagnosis. From all ordinary chloasmata and pigment-macules the 
spots of erythrasma are distinguishable by the ease with which the 
superficially embrowned epidermal layers are removed by erasion. 
Tinea versicolor is distinguished from erythrasma with greater diffi¬ 
culty; but the latter occurs in different situations by preference, its 
patches are more vividly red, and the parasite, under the microscope, 
presents distinctive features. 

The treatment is that of tinea versicolor; and the prognosis is favor¬ 
able, subject to the disappointments arising from frequent relapses. 

La Perleche. Under this title, Justin Lemaistre, of Limoges, 1 
describes a contagious disease observed by himself in more than three 
hundred children of his city. It is characterized by dryness, smarting, 
cracking, and excoriation of the lips, the epithelium of which becomes 
blanched, macerated, and readily detached. Hemorrhagic and painful 
fissures form in the direction of the commissural folds. Often plaques 
are visible suggesting mucous patches. The disease lasts for from 
fifteen days to a month, with possible recurrences which mav lead to 
a year’s suffering. 

The disease is supposed to be of parasitic origin, communicated by 
drinking from cups used by infected persons. Lemaistre attributes 
the disease to a streptococcus plicatilis which he has cultivated in Pas¬ 
teur flasks. The microbes were originally found on the borders of 
epithelial cells of the lips of infected children. The parasite lives in 
the form of a micrococcus in stagnant water, wells, and springs. The 
disease is one of uncleanliness, and is readily prevented by appropriate 
hygiene. 


PINTA DISEASE. 

(Spotted Sickness, Mal de los Pintos.) 

This is a disease occurring in the tropics, supposed to be due to a vegetable parasite. 

The disorder thus named, described by Hirsch, 2 Iryz, and others, 
occurs chiefly in the tropical portions of South America. Its lesions 
are variously colored, shaped, and sized patches, increasing by cen¬ 
trifugal extension over the face, the extremities, and in general, except 
the palms and soles, upon regions exposed to the air. The hue of the 
patches varies from a grayish-white to a deeply pigmented shade, 
differing with different individuals aud also exhibiting various shades 
upon one affected subject. The scales which are formed over the 
patches are of pityriasic type, larger in extreme cases. The hairs are 
reported to be changed in color and to fall from their pouches. Ulcer¬ 
ation is a complication of the severer forms of the disease. The 
affected surfaces are intensely pruritic. 


1 Le Progres Medical, October, 1884. 


2 Loc. cit. 


PARASITIC AFFECTIONS. 


757 


In some patients a bluish color characterizes the affected parts, that 
in spots suggests a tattooing with dark powder. The disease is reported 
to last for months or for years. It occurs at all ages and in both 
sexes; is more common among the poorer and neglected classes; and 
is rarer among the whites. 

The fungus supposed to produce the disorder consists of mycelial 
threads bearing conidia, and rounded or oval spores. It is, like the 
other mould-fungi, limited in its habitat to the epidermis; and as 
respects treatment, it yields to the parasiticides employed for the relief 
of other diseases of the same class. 


2. DISEASES DUE TO ANIMAL PARASITES. 

Scabies. 

(Lat scabere, to scratch.) 

(“ The Itch.” Ft., Gale; Ger., Kratze.) 

Statistical frequency in America, 2.58. 

Scabies is a contagious cutaneous affection, characterized particularly by the forma¬ 
tion of a cuniculus, or furrow, produced by the acarus scabiei which is the cause 
of the disease, as also by the occurrence of several of the elementary lesions of 
the skin, accompanied by itching. 

Symptoms. Scabies is a disease of polymorphic symptoms, which 
may be viewed as an artificial eczema or dermatitis, produced by the 
invasion of the itch-mite (Fig. 99). According to the extent to which 
the skin is primarily invaded by the parasite, or is secondarily injured 
by the traumatism which follows severe scratching of its surface, will 
its objective symptoms differ. 

Prominent among the objective symptoms is the cuniculus, or acarian 
furrow, an elongated gallery excavated in the epidermis by the female 
acarus soon after her impregnation by the male. The male does not 
enter the skin, but is lodged beneath the crusts or other exuvise which 
gather upon its surface. This cuniculus, or furrow, is a whitish or a 
yellowish, slightly arciform, linear lesion, with regular parallel borders 
covered with dots or specks of blackish aspect, representing feces of 
the mite. The furrow (Fig. 100) terminates at the upper extremity 
by a vesicle, pustule, or exfoliation of the surface at the site of an 
infundibuliform depression; and at the deeper extremity by a whitish 
and yellowish, shining and salient point, representing always the acarus. 
This is the most characteristic symptom of scabies. 

The “ head” of the gallery is usually whitish, where the parasite 
first entered the skin, and it is also more elevated than the “tail,” 
where the acarus rests after laying its dozen or more of eggs. At 
times the entire cuniculus forms an elevated ridge, rather than a 
thread-like depression, with white dots along its summit. When the 
roof of the vesicle at “ the head” is torn off by scratching, the effec 


758 


DISEASES OF THE SKIN. 


is to produce a reddened spot at its site, surrounded by a whitish 
moat running around the spot to the entrance of the gallery. 

When the burrow exists it can most perfectly be recognized in the 
interdigital spaces and on the skin of the penis, as a tangential line, 
running from a vesicle, papule, or pustule to a distance of from one- 
eighth of an inch to an inch. It resembles a beaded, dotted, yellowish 
or blackish thread, the color being more pronounced in comparison 



Fig. £9. 


Female acarus fecundated (ventral surface). An ovum arrived at maturity is visible 
within the body (After Kaposi). 

with a fresh-colored and washed skin, and less marked in contrast with 
a soiled surface; being, in a soiled and subsequently washed integu¬ 
ment, most conspicuous in proportion as the small puncta have served 
to entrap particles of dirt. The cuniculus may be curved, angular, 
or tortuous; and occasionally may be seen well-nigh completely cov¬ 
ered by a bulla, pustule, or vesicle extending its entire length. In 
these cases, however, the female always penetrates beyond the periph 
eral wall of such lesion, working her gallery beyond it and mor 
deeply, lest she be lifted by the exudation out of reach of the succulen 
rete where she feeds. 





PARASITIC AFFECTIONS. 


759 


Hebra points to the fact that between two parallels, one drawn 
through the nipples and another at a short distance above the knees, 
on the anterior face of the body, can be recognized the greater part of 
the eruptive lesions in every case of scabies. 


Fig. 100. 



Acarian farrow, from the lumbar region. The female acarus is visible at the terminal 
extremity of the furrow with ventral surface exposed, and containing a mature ovum ; two ov a 
Z'tZ have been laid during the day ; the third exhibits traces of the embryo ; the twelfth 
exhibits ’a mature larva (a); twelve empty shells are also seen ; between these the feces are repre¬ 
sented by black points (after Kaposi). 


The disease is indeed one peculiar to those classes which are the 
familiars of filth and poverty, occurring among these at all ages and 



760 


DISEASES OF THE SKIN. 


in both sexes. As a matter of accident, it may appear, though 
rarely, in individuals of high social station. It is much more common 
in Scotland, Austria, Prussia, Sweden, Norway, Prance, and the 
Orient, than in America. During the late Civil War it prevailed 
with relative frequency among the masses of Americans associated 
in regiments with foreigners who had been but a short time in the 
country; and steadily decreased after that time. But few cases were 
until lately seen annually in the public clinics of our large cities, though 
here and there, chiefly among newly arrived immigrants, isolated 
“ nests” of the disease were discovered. The later influx of immi¬ 
grants to the United States (notably the Columbian Exposition of 
1893) has, however, in the last few years, again brought the disease 
into prominence by reason of its greatly increased frequency. 

In consequence of the irritation produced by the parasite and the 
traumatisms of scratching this furrow, all the symptoms of acute and 
chronic eczema are presented in the region invaded. These indications 
are vesicles, pustules, wheals, small papules, hyperemia of the skin 
upon which these rest, crusts formed by dried serum, pus, and blood, 
excoriations, fissures, and, in cases of long standing, pigmentation of 
the skin where the disease has existed. These lesions may coexist, 
several appearing at the same time upon the skin of an affected indi¬ 
vidual; small vesicles and pustules, with perhaps a few short cuniculi 
visible upon their summits; excoriations; larger and longer cuniculi 
interspersed between inflammatory papules; a tumid skin, evidently the 
seat of a mild grade of dermatitis; and crusts here and there, beneath 
which male and young acari are ensconced—such is the composite 
picture of a typical eruption in scabies. 

It will be remembered that the acarus family find nutriment, shelter, 
and all they require on the person of the individual whose skin they 
inhabit; and there is no inducement for them to colonize at the instant 
of the first opportunity offered. The transfer of a male acarus alone, 
from one person to another, would not insure a generation of the young; 
and the unimpregnated female could not alone do more. As for the 
impregnated female, Hebra, on several occasions, failed to induce 
scabies when one such female only was transferred intentionally to a 
souud skin and was seen to penetrate it. Lastly, the eggs alone would 
not suffice, for they have to be nicely planted within the epidermis, 
in order to be hatched safely to maturity. In brief, only the more 
intimate contacts of the bed at night, and the application of nails 
charged with acari of both sexes, especially the young, are to be 
regarded as most effective for the transmission of the disease. This 
fact explains why nearly seven men are found to be affected with 
scabies to one woman. Women, as a rule, are more inclined to sleep 
alone, or with those only to whom they have family ties; while labor¬ 
ers, boys, apprentices, and persons of that class, including those who are 
strangers to each other, at times occupy the same beds, especially in 
large cities, where they are often huddled together at night like swine. 

The intruder may be recognized always at the terminal extremity 
of her gallery, for it is now known that she does not in her lifetime 
leave it for any purpose, as was at one time taught. The female acarus 


PARASITIC AFFECTIONS. 


761 


here shows as a minute, whitish, clearly defined dot, presenting a con¬ 
trast in this particular with the blackish feces in the gallery behind, 
and .may, in a good light, by a person of some dexterity and fair 
eyesight, be extracted on the point of a cambric needle from her 
lodging-point. It is important to know that this parasite may be recog¬ 
nized by the unaided human eye. Its characteristic tortoise-like body 
exhibits most of its anatomical peculiarities under a glass enlarging 
the figure but one hundred diameters. 

The regions affected by the eruption are the palms (especially of 
women and children) and the dorsal surfaces of the hands; the flexor 
aspects of the wrist-joints; the sides and roots of the fingers and toes; 
the feet (and, especially in women, the delicate skin of the feet near 
the instep, partly dorsal, partly plantar in situation); the buttocks 
(more particularly in those who are seated in the trades and occupations 
of life); the extensor faces of the joints; the belly, the penis and scro¬ 
tum in men; the anterior folds of the axilla?; the nipples and breasts of 
women; the elbows and knees, rather than the popliteal space and bend 
of the elbow; and the anal region. Scabies, prurigo, and pruritus are 
alike in this, that in each the face and posterior aspect of the body 
display the fewest of any lesions visible. In general, portions of the 
body subjected to constant pressure by the clothing, as, for example, 
the regions pressed by the corset of the woman and the waistband of 
the trousers in man, are sites of predilection. In other cases the dis¬ 
ease is encountered in the axillae, the groins, and, as a matter of rare 
exception, over the entire surface of the body. 

The itching of scabies is occasionally severe, and has, in fact, con¬ 
ferred upon the disease its familiar English title, “ the itch.” This 
sensation is usually worse at night, when the parasite is rendered 
active by the heat of the body in bed, retained by the bed-clothing. 
It differs somewhat in different cases, being at times the cause of but 
little complaint. There is nothing characteristic, however, in the 
occurrence of this symptom, as equally severe pruritus accompanies 
eczema unconnected with parasites. 

The itching which results from the epidermic tunuelling in progress 
is often noticeably more severe than would be suggested by the moder¬ 
ate number of skin-lesions visible. When these lesions (puncta, vesi¬ 
cles, pustules, blebs, papules, resulting crusts, furrows, excoriations, 
etc.) are found upon the hands, the itching becomes so great that the 
infested person scratches also the accessible parts of the skin, where 
there were originally no acari, such as the inner side of the thighs, the 
lower belly, etc., as Hebra suggests, simply because they are “ handy.” 
Hence it is that the picture comes to resemble that of all pruritic and 
scratched skins. 

Several artificial forms of this polymorphic affection are occasion¬ 
ally noted. In children the face may become diseased after contact 
with the breast of the mother or the buttocks after contact with the 
flexor aspect of the nurse’s arm. Large vesicles, and even rupioid 
bullae, may result from the irritation of their tender skins. Again, 
in subjects predisposed to eczema for any reason the invasion of the 
parasite in one region of the body, possibly a region of preference, 


762 


DISEASES OF THE SKIN. 


may originate an eczema in another locality whither the parasite has 
not wandered. In other cases the most exaggerated forms of eruption 
are seen, usually in persons of filthy habits who have long suffered 
from the malady. Thus extensive epidermal callosities form, filled 
with debris of dead parasites unable to find nutriment longer in the 
cornified rete; or extensive greenish and blackish crusts cover colonies 
of acari which survive beneath them for generations of their race. The 
nails in such extreme cases may be involved. The so-called Scabies 
Norvegica, or “ Norwegian itch,” belongs without doubt to this class. 
As a rule, however, the disease does not advance to these severe grades. 
The parasites having gained lodgement in the skin produce characteristic 
symptoms of the disease in the average of cases, and though unrecog- 
nized, and persisting for weeks, are the sources of so much annoy¬ 
ance that treatment of some sort is instituted which is apt to restrict 
the extension of the malady, certainly in America, within moderate 
limits. Usually after lodgement is effected, a week or a fortnight 
elapses before the first characteristic furrow is formed, though the 
pruritus is of earlier occurrence. The extension of the disease by the 
maturing and ravages of young acari requires a few weeks more, so 
that in the course of from two to three months the evolution of the 
malady may be considered as complete. In the course of about three 
months more the disease, unchecked, may become generalized. 

Even the animal parasites elect the soil upon which they thrive, and 
indeed, after such election, thrive well or ill, according to the condi¬ 
tions present. This is not only exemplified in the matter of individual 
susceptibility, but in the conditions of health of an affected person. 
Thus, in puerperal and typhoid fevers and other grave states of sys¬ 
temic disturbance, the parasites perish in the skin and the eruption 
disappears; classical symptoms recurring in convalescence if one or 
more acari have survived with sufficient vigor to reproduce their 
kind. 

Etiology. The disease is produced only by the acarus scabiei (or 
sarcoptes scabiei) and is thus contagious, the parasite being introduced 
upon the surface of one individual, mediately or immediately from 
the skin of another infested man or an animal. All persons are sup¬ 
posed to be susceptible to the disease, but the difficulty of intentionally 
transmitting it by contagion is greater than that of inducing the leech 
to fasten itself indiscriminately upon any given skin. The brief 
shaking of the hand or transient personal contacts of the daytime are 
certainly in many cases quite insufficient for contagion. Few practi¬ 
tioners of medicine suffer after the most careful examination of a 
patient. When a case is exhibited at the clinic, it is minutely, and 
without ill results, examined by dozens of students. It is probable 
that the contacts of the night, incidental to the occupation of the same 
bed, or the use of gloves and other articles of apparel containing para¬ 
sites or their ova, are essential to the transmission of the disease. 

Pathology. The pathology of the eruption induced by the parasite 
is that of the various phases of exudation. The differences between 
scabies and all other eruptions of similar type, depend, in the case of 
the former, upon the peculiarities of the exciting cause of the disease. 


PARASITIC AFFECTIONS. 


763 


In the description of this, the acarus scabiei, aid has been derived from 
the admirable chapter devoted to this subject by Kaposi. 

The female acarus (Fig. 99), visible as a yellowish white dot at the 
cul-de-sac of her subcutaneous gallery, and removed hence on the 
point of a fine needle, is visible to the naked eye, but is best examined 
under the microscope. The body is oval, with a short projecting head 
and a convex dorsum transversely corrugated, with short spinous pro¬ 
cesses projecting for the most part backward, a direction largely fol¬ 
lowed also by the eight long bristles which are most noticeable at the 
posterior extremity of the trunk. The posterior portion of the dorsum 
also exhibits a series of recurved, short, hoop-like projections, arranged 
circle-wise, about the anovaginal orifice. 

The flat ventral surface exhibits eight short claws or legs, four ante¬ 
rior and four posterior. The former are set near the head, and are 
provided each with hairs, and a long pedunculated sucker; the latter 
are armed solely with long, straight bristles. All the eight legs have 
fine articulations. The head is oval in shape, and is provided with 
four pairs of mandibles and six palpi. There are two ventral outlets; 
and a stomach, intestines, ovaries, muscles, and even mature ova can 
be recognized internally. 

The males are smaller than the females and fewer in number. They 
differ also in this, that the posterior extremities are provided with suck¬ 
ers and stalks, as are the anterior extremities of the female. Situated 
between the stalks and the median line is a horseshoe-shaped mass of 
chitin ensheathing a fork-shaped penis. They are said to die in the 
course of from six to eight days after copulation with the female. 
The latter survive from twenty to sixty days. 

The female alone, as has already been said, penetrates the epidermis. 
This act she accomplishes by inserting the head first into the tissues 
of the skin, the body disappearing afterward, and depositing behind, 
in the course of her progression downward, from one to two eggs daily 
until from twenty to fifty have been laid. The eggs are oval, their 
longitudinal axes placed transversely to the cuniculus. In the two 
or three eggs found nearest the female, only a yellowish color can be 
distinguished ; in the third to the fifth, traces of the embryo are recog¬ 
nizable; the sixth to the ninth contain larvae; and, in the oldest, the 
head and front legs can be discerned. When mature the shell of the 
ovum is ruptured, usually between the third and sixth day, and the 
young acarus reaches the surface of the skin, either by making exit at 
the original point of entry of the mother, or by the rupture of the roof 
of the burrow. It subsequently buries itself in the skin for a brief time, 
while the process of casting its slough is completed. There are three 
of these periods in existence. Before the first period is accomplished, 
the young acarus is provided with but two pairs of posterior extremi¬ 
ties, two anal bristles, and ten dorsal spines. After the first period it 
is an octopod with four oval bristles and twelve dorsal spines. At the 
second period it gains two dorsal spines, and after the third it pos¬ 
sesses fourteen. The acarus survives but a few days when removed 
from the skin and immersed in liquids which protect it from the air, 
such as water, oil, etc. 


764 


DISEASES OF THE SKIE. 


The transmission to man of the acarus peculiar to the horse, cat, 
sheep, rabbit, elephant, etc., may be accomplished; but the colony 
under these circumstances rarely thrives. The same is true of the 
human acarus when transferred to the lower animals. 

Diagnosis. The diagnosis of scabies must rest upon the recognition 
of its special features described above. There are no lesions peculiar 
to the disease save the cuniculi, or furrows, made by the parasites, and 
they, it will be remembered, do not appear until one or two weeks 
have elapsed after the infestation. They may also be obliterated or 
be concealed by excoriations when the finger-nails plough them open, 
or by pustulation and subsequent crusting when the irritation induced 
is excessive. In every well-marked case, however, cuniculi can be 
discovered, if not on the fingers, wrists, or forearms, at least on the 
penis, the breast near the nipple, or upon some other covered portion 
of the body. With care and a little dexterity, a fine cambric needle 
can then be forced into the furrow well down to and a little beyond 
its remote cul-de sac, and th efons et origo malorum be thence extracted 
and placed under the objective of the microscope. 

Next to the cuniculus and its inmate or inmates, the two most im¬ 
portant diagnostic features of scabies are the polymorphism of the 
eruption and the sites of its most frequent occurrence. These sites 
may be named first, as the more important of the two. Few skilled 
diagnosticians would fail to entertain a suspicion of scabies in a case of 
supposed “ eczema,” existing upon the fingers, wrists, and penis only, 
or upon the breast of a mother, and the face and buttocks of her infant, 
or the arms of its nurse. 

At the same time it is a matter of great importance to remember 
that eczema is often attended with very severe itching; that this sen¬ 
sation may be intensely aggravated after retiring to bed at night; that 
eczema is often limited to the hand; is not rarely characterized by 
interdigital vesicles and pustules; and is, indeed, in America very 
much the more frequently encountered of the two diseases. The vulgar 
oonception of scabies holds to the belief that the disease is exceedingly 
common; that every severe itching with a cutaneous exanthem is pro¬ 
duced by “ insects ” or “ worms” in the skin, and that transient casual 
contacts are abundantly capable of transmitting the offending parasite. 
Many more cases of simple eczema are supposed to be scabies than the 
reverse. There are few villages in this country which cannot lay claim 
to an “ itch,” often known by a name of local significance. Among 
these provincial titles may be counted the “ prairie itch ” of the West. 
These affections are, as a rule, forms of eczema quite unconnected with 
the existence of a parasite, and incurable generally by the parasiticides 
too often employed to “ kill” the disease. In all such instances the 
absence of the characteristic features of scabies described above, the 
absence of a history of contagion, and the presence of that of an alter¬ 
nating relief and aggravation of the symptoms, will point to the real 
character of the malady. In the severe pruritic affections of the West 
and the Northwest, that the reader will find described in the chapter 
devoted to the several forms of pruritus, it is noticeable that the 
patients are often cleanly—those who are careful as to the hygiene of 


PARASITIC AFFECTIONS. 


765 


the body. Scabies is really a filth-disease, and is best recognized 
among the filthy classes. Of diagnostic importance is the relative 
rarity of scabies among other cutaneous affections, pruritus included, 
observed in the United States. 

The Statistical Committee of the American Dermatological Associa¬ 
tion from the 1st of July, 1878, to the 1st of January, 1893, reported 
204,866 cases of skin diseases of all kinds occurring in the United 
States and Canada. Of this number 8306 were instances of scabies, 
a percentage of 4.054 to the total number of affections tabulated. The 
influence of temporary increase of population and of the crowding 
together of persons in large centres, many of whom came from foreign 
countries, is well illustrated by the statistics of scabies in the year 
following the Columbian Exposition, held in the city of Chicago. 
During the year of the Fair, 1893, 901 cases of scabies were reported 
in the United States. During the year 1895, however, but two years 
afterward, the total number of cases of scabies was but 383, the pro¬ 
portion to all cutaneous disorders being 2.531. 

Treatment. The treatment of scabies has in view the destruction 
of the parasite and the relief of the cutaneous disorder which the former 
has induced. Ordinarily these two indications are fulfilled at the 
same time. The destruction of the parasite is usually followed by 
relief of the resulting cutaneous lesions; and the skin, freed from the 
burrowing acari, is no longer tormented by the scratching which, in 
extreme cases, is not only irresistible but also an important element in 
the aggravation of the lesions. In other cases, however, the resulting 
eczema or dermatitis persists after the removal of the original cause of 
the disease, and it demands special attention. Care should always be 
had to avoid treating the delicate skin of the infant with the severer 
remedies efficacious upon the thicker integument of the adult. 

Sulphur, in all its forms and various combinations, has long held 
the highest esteem in the treatment of the disease. Other remedies, 
however, of acknowledged efficacy are employed with satisfactory 
results, most of them owing their usefulness to the strong odor they 
emit. Among these remedies may be named carbolic acid, petroleum, 
naphtol, the oils of cloves, cinnamon, rosemary, and mint; tar, balsam 
of Peru, and balsam of tolu; styrax, staphysagria, Vleminckx’s solu¬ 
tion heretofore described, and sapo viridis. 

Sulphur is commonly employed in the form of an ointment, 1 to 2 
drachms (4.-8.) to the ounce (32.), firmly, thoroughly, and carefully 
rubbed, first into the affected patches, especially between the individual 
fingers ^or toes), about the wrists, over the palm and dorsum of the 
hand, into the axillae, about the nipples, penis, buttocks, or other 
invaded parts, and, finally, over the cutaneous surface in general, the 
head alone excepted. If no severe eczematous complications exist, the 
inunction is well preceded by a warm soap, or a warm soft-soap-ancl- 
water bath. But in the event of such complication the bath should 
be deferred as decidedly injurious iu the inflamed condition of the skin. 

The first inunction is preferably performed at night, after which the 
patient retires to his bed enveloped in woollen underclothing or 
wrapped in a blanket. It is neither wise nor necessary to induce 


766 


DISEASES OF THE SKIN. 


sudation by these measures, for the skin is best retained in simply a 
greasy condition, unmacerated by sweat. In England it is customary 
to bathe on the eusuing morning, but it is preferable to defer the bath 
until the cure is complete, however disagreeable the conditon of the 
iutegument may be to the sufferer. The sulphur inunctions are thus 
repeated for three successive nights, a thorough warm soap-and-water 
bath being finally employed for the purpose of cleanliness. The cloth¬ 
ing meantime should be either thoroughly disinfected with sulphur, 
be immersed in boiling water, or be subjected in a stove or furnace to 
a dry heat capable of destroying all acari and ova which may adhere 
to it. 

In France, the routine treatment of scabies is always preceded by 
a thorough friction for twenty minutes with soft soap, special attention 
being as usual directed to the invaded areas. This operation is at 
once followed by a bath in warm water, during which the surface is 
also thoroughly scrubbed for from thirty minuutes to an hour. Lastly, 
the parasiticide is well rubbed on for fifteen minutes, the patient is 
re-dressed in the underclothing (disinfected during the progress of the 
bathing), and the final cleansing of the skin with water is practised 
within twenty-four hours. 

When a resultiug eczema demands attention it is to be treated in 
accordance with the general principles considered in the chapter devoted 
to that subject. In this case the dusting-powders, the oleated lime- 
water, and the zinc, diachylon, and even more stimulating ointments, 
may be employed with advantage. Generally, after a vigorous course 
of external treatment with sulphur, the patient should be instructed 
to defer any further topical applications to the skin for a week or more, 
in order to test the efficacy of the method pursued. 

One of the following formulas may be substituted for the ordinary 
sulphur ointment: 


R.— Sulphur, flor., 

3 xi .); 

481 


Potass, subcarb., 

3 y j; 

24 


Adi pis, 

3i x ; 

288 j 

M. 


Hardy’s modification of Helmerich’s ointment. 


R.—Stvracis liq., 

f 3J ; 

4 


Petrolei, l 

01. olivae, j 

aa f Jjss; 

16 

Balsam. Peruv., 

Spts. sapon. virid., 

f 3 ijss; 

10 


f 3 v ; 

201 M. 

R.—Potass sulpliuret., 

3 v ; 

20 

[Kaposi.] 

Sapon alb , 

3 xx 1 

80 


01. oliv., 

f 3 iv; 

16 


01. thym., 

gtt. XV; 

1 

M. 

R.—Sulphur, sublim., \ 

Balsam. Peruv., / 

aa 3 ss; 

2 

[Jadelot.] 

Adipis, 

Zj ; 

32 

M. 

For use especially in the scabies 

of children. 

[Duhring.] 



PARASITIC AFFECTIONS. 


767 


Hebra’s modification of Wilkinson’s salve, Vleminekx’s solution, 
and the balsam of tolu are employed for the same purpose. 

Kaposi’s naphtol formula is: 


HNaphtol., 

Sapon. virid., 
Cret. alb. pulv , 
Axung., 


15 parts; 
50 parts; 
10 parts; 
100 parts; 


M. 


McCall Anderson much prefers, on account of its pleasant aroma: 


H.—Styracis liquid., % j ; 321 

Adipis, % ij; 64i M. 

Melt and strain. 

or Schultze’s modification of Pastav’s formula : 

&. —Styracis liquid., f J j ; 32, 

Spts. rectificat., t3U5 3 

01. olivee, f 3JI 4 I M - 


Ft. liniment. 


Prognosis. Scabies is an entirely curable disease, even after persist¬ 
ence for long periods of time. When, however, complications exist, 
or severe eczema continues after the efficient action of a parasiticide, 
the patient may experience some delay before attaining complete resto¬ 
ration to health. 


Demodex Folliculorum. 


(Steatozoon or Acarus Folliculorum. Ger., Haarsackmilbe.) 

This parasite was discovered in 1841 by Henle. It is a microscopic 
creature in the form of an elongated and jointed worm, with head 
separated from the thorax, and eight legs, four on each 
side, each leg with three articulations, and terminating 
in three small hooklets. The posterior extremity of the 
body is a vermiform appendage, terminating in a conical 
point (Fig. 101). 

The demodex folliculorum is found long after birth 
upon the free surface of the integument, those parts of 
the skin particularly where the sebaceous glands are 
large, and on patients affected with acne or seborrhea 
oleosa, as well as upon those free from all evidence 
of disease. It is encountered also in the substance of 
the comedo-plug, where at times from five to twenty 
may be discovered in a single follicle. It is, however, 
in no case the source of disease. A demodex, which 
is considered to be a variety of that discovered upon the 
skin of man, infests dogs, mice, and other lower animals ; 
and may in the latter be the source of disease charac¬ 
terized by furuncular lesions, abscess, and even fatal 
results. None of these parasites is, however, known Dem0( j ex f 0 ni C u- 
to be transmissible to man. lorum. 




768 


DISEASES OF THE SKIN. 


Pulex Penetrans. 

(Rhynocoprion Penetrans, Sarcopsylla Westwood, Nigua, 
Chigoe, Jigger, Sand-flea.) 

The Sand-flea is a minute, brownish-red, egg-shaped parasite 
which penetrates the skin of man and of the lower animals, including 
rats and mice. It is encountered chiefly in tropical countries, but is 
said to exist in northern latitudes, even in some of the Southern States 
of the United States. Fecundated females only attack the skin, in 
man usually about the toes or near the nails, entrance being effected 
with scarcely painful pricking sensations. In the course of from five 
to ten days a painful oedema with pustulation follows, occasionally 
accompanied by lymphangitis or severer symptoms in the form of gan¬ 
grenous abscesses. These sequels are said to result from the distention 
of the ovary of the parasite, which may exceed fivefold the original 
dimensions of the insect. 

The treatment of the disease is the extraction of the flea by the aid 
of a heated needle, whereby it is simultaneously destroyed. The 
resulting wound may be cauterized or dressed antiseptically. 


Pulex Irritans. 

The Flea which specially attacks man is a brownish-red insect 
having a laterally compressed body, an oral haustellum, serrated soft 
mandibles, a tongue sheathed in an inferior labium, and a pair of 
labial, four-jointed palpi. Each of the triple segments of the thorax 
bears a pair of five-jointed, double-clawed legs. The male is from 
2 to 5 millimetres in length and 1 to 2 in breadth, the female being 
nearly twice that size. The female deposits her eggs in any fissure, 
crevice, or fold of garment or furniture which may be accessible, from 
which the larvae are produced in a week. The nympha is enfolded in 
a cocoon, but only the mature insects prey upon man. According to 
Geber, the insect injects an irritating fluid into the skin at the moment 
of attack. The lesion it produces is a hemorrhagic punctum, followed 
by a transitory hyperemia and a hemorrhagic exudation which may 
persist for a few hours. 

The central punctum, or point, distinguishes the wound produced 
by the insect from macules of simple erythema; but care should be 
taken when fever is present to exclude the symptomatic erythemata. 
The site of the wound may become an utricarial wheal. 

Mixed cases of fleabites with wounds produced by bugs and lice are 
often seen in the lowest classes applying for relief to public charities;, 
and the deeply pigmented skins they exhibit, often with purpuric 
lesions distributed over the lower extremities, and commingled with 
syphilitic eruptions, are in the highest degree confusing. The practi¬ 
tioner should always be on his guard in pronouncing on these cases, 
especially if the purpuric blotches occur in the cachectic and those 
suffering from other diseases than those of the skin. 


PARASITIC AFFECTIONS. 


769 


Filaria Medinensis. 

(Dracunculus Medinensis, Guinea Worm.) 

This parasite is a nematoid worm, which, after invasion of the human body, induces 
a tumefaction of the skin which may result in an abscess and a discharge of the 
worm wholly or in part. 

Symptoms. The lesions due to invasion of the skin by the dra¬ 
cunculus medinensis are first observed at the point where the worm is 
about to make exit, which point may be at a considerable distance from 
that where it entered, and the exit may be made after an interval of 
several weeks or months. This approach to the surface for the pur¬ 
pose of securing exit is accomplished only when the worm is quite 
mature. After some local sensation of tension or of itching, a pea¬ 
sized to small nut-sized vesico-papule forms, superficial or subdermic 
in situation, which, after accidental or intentional rupture, gives exit 
to a clear serous fluid in which the uncolored head of the worm may 
be recognized. The head, which is surrounded by a quantity of leuco¬ 
cytes, appears either at once or in the course of a brief time, producing 
slow and sinuous movements by alternate contractions and elongations. 
The entire worm and its young may then wholly be extruded in the 
course of a week or more; or the head may be withdrawn and another 
swelling form at another part of the surface, the first meantime closing; 
or, in badly managed cases, the worm may be torn so that the head 
only is removed, and then a severe lymphangitis with inflammatory, 
suppurative, and even gangrenous symptoms may supervene, produc¬ 
ing, in fact, the train of symptoms now well recognized in connection 
with septicemia. 

In some cases, however, the body may be discharged later than the 
head, after the mechanical separation of the latter, without serious 
consequences. The escape of embryos into the adjacent tissue is also 
regarded as a grave complication. 

The chief sites of exit are the foot—particularly the heel—the leg, 
thigh, buttocks, scrotum, hands, trunk, neck, and face. There is 
usually but one worm in a single subject of the disease, but the num¬ 
ber may be indefinitely large in persons exposed. 

Etiology. The disease is produced by the ingestion of water con¬ 
taining the larvae of the parasite. Though denied, it seems highly 
probable that it may also obtain access by a traumatism inflicted at a 
date prior to that of invasion. The fact that nearly two-thirds of all 
cases occur in the foot is not without significance. Young filariae have 
been seen penetrating the microscopic crustaceae in fresh water, the 
later ingestion of which in drinking-water is supposed to be effective 
in the production of the disease. 

The disorder due to the guinea worm is endemic in India, Arabia, 
and Persia; it is also found in Egypt, Africa, and portions of South 
America, but with greater rarity. . . 

Pathology. The female alone invades the human body; it is a fili¬ 
form and uniformly cylindrical body from three to four metres long 
and one or two millimetres in thickness. The head is convex, with a 

49 


770 


DISEASES OF THE SKIN. 


central oral orifice surrounded by four papillae. It is viviparous, the 
embryos numbering millions, each embryo measuring 0.05 millimetre 
in length and 0.02 in thickness, with a head somewhat thicker than 
the body, no buccal orifice, and a pointed tail. In from ten to a max¬ 
imum of fifteen months the maturity of the female which has been 
impregnated is attained, and the parasite finds its way from muscles 
or other tissues in which she has been lodged or to which she has trav¬ 
elled to the surface of the body. 

The diagnosis (to be made in countries where the disease is endemic) 
is based upon the discovery of the worm. 

Treatment. The usual method of treatment by the natives of the 
countries named is to secure carefully the head when it appears, and 
to wind out the worm very gently day after day until the entire body 
is extracted, securing the accessible portion by winding it about a bit 
of stick or of paper. Continuous irrigation of the wound is both 
recommended and practised where the disease is common. The tinc¬ 
ture of asafetida has also been employed to destroy the parasite. 

Manson, 1 who has given the subject much careful study, has en¬ 
tered a protest against winding out the guinea worm, stating that at 
best this process merely shortens by a few days the duration of treat¬ 
ment in case the parasite is properly situated in the tissues without 
twists or turns, or if it has arrived at a stage of life when, having dis¬ 
charged all its young, it is ready to come out spontaneously. If, as 
is often the case, the worm is twined and twisted among the tissues, 
and if she is still emitting her young, she will resist traction, a 
process which will often residt in rupture. In consequence of rup¬ 
ture at this time myriads of young escape into the tissues, producing 
violent inflammation, which is frequently accompanied by secondary 
infection and possibly by sepsis. To determine if the worm is ready 
to come out spontaneously, the opening of the tumor may be douched 
for a number of minutes at a time, several times a day, by dripping 
cold water over it. When under the influence of this douching the 
worm no longer emits young careful winding out is not objectionable. 
The treatment Dr. Manson recommends for trial in all cases is one 
first employed by a French naval surgeon, Dr. Emily. The swelling 
produced by the worm when she begins to approach the skin and 
before she has pierced it, is injected in several places with a solution 
of bichlorid of mercury (1 :1000). This kills the Avorm, Avhich may 
be subsequently absorbed, or if cut down upon a day or tAA^o later her 
body can easily be withdrawn. In case the head of the Avorm be 
already protruding, the solutiou may be injected directly into her 
body, Avhich is easily removed the folloAving day. A number of cases 
have been treated in this Avay successfully, and with no disagreeable 
results in the way of pain or inflammation. This method also reduces 
the time of treatment from not less than four Aveeks to the much 
shorter period of four or five days. 

The prognosis is favorable, save in cases where septicemic symptoms 
develop as a consequence of coccogenous infection. 


British Journ. Dermat., Feb. 1896. 


PARASITIC AFFECTIONS. 


771 


Craw-Craw. 

(“ Papulose Filarienne ”) 

This rare affection was originally described in 1875 by Silva Aranjo. 
It has since been studied by Nieliy, 1 O’Neill, Manson, and others. 

It occurs only on the West Coast of Africa, chiefly among the negroes, 
in whom papules, vesicles, pustules, and vesico-pustules appear as 
single, multiple, and disseminated or grouped lesions accompanied with 
severe pruritus. The scratching of the affected part is excessive, and 
the crusting at times is a prominent feature of the disorder. As a 
whole, the disease assumes an inflammatory aspect and is superficial 
in situation. The regions involved are the arms, forearms, and hands, 
the feet and legs, and several portions of the trunk. 

By removal of the crusts and erasion of the soft tissue beneath, it 
is said that in some cases* the disease has been brought to an end. 
Other observers, after removal with a knife of the apex of selected 
lesions, have recognized a nematode filarial parasite, displaying two 
blackish points near its head which are said to distinguish it from 
filaria medinensis. The parasite of craw-craw is apparently related to 
the latter, and is supposed to belong to the family of the Anguillulidce 
or Anguillulce, a class of parasites discovered in some portions of 
Europe among the lower animals. 


Cysticercus Cellulosae Cutis. 

Oysticerci have been recognized in the skin and subcutaneous tissues 
by Rokitansky, Lewin, Guttmann, Schiff, F6rreol, Duguet, and other 
observers. In these cases one or many roundish, firm, elastic, cutan¬ 
eous or subcutaneous, pea- to walnut-sized tumors, isolated or dissem¬ 
inated, unproductive of pain, project from the general level, and are 
enveloped by an unaltered integument. They occur upon the trunk 
and the extremities. They remain in this condition without change 
for years; and may accompany cysticerci of the brain and other por¬ 
tions of the body, productive of the serious disturbance of the economy 
which such invasion may determine. If the skin tumors be opened 
and their contents examined, the parasite will be recognized as an 
ampulliform sac, with a cephalic appendage, reentrant or projecting, 
and provided with four suckers and a coronal of hooklets. By no 
external characteristics could such tumors be distinguished from others 
of similar size and external appearance. Only in the rare cases of 
nervous complication could a suspicion arise based upon the real char¬ 
acter of the disorder. Respecting this matter, however, the diagnos¬ 
tician is in no worse position than when called upon to recognize 
cysticerci of the viscera. Cysticerci of -the liver are distinguished 
during life, and subsequently removed by operative procedures. 

The diagnosis is from gumma, lipoma, epithelioma, and sarcoma. 


1 Bull, de l’Acad. de Med. de Paris, 1882, p. 395. 


772 


DISEASES OF THE SKIN. 


The first occurs only in the syphilitic; the second has a peculiarly 
uneven surface and firm feeling; the third is largely facial in situation; 
and the last is of a plainly malignant character and relatively rapid 
career. 


Echinococcus. 

Weyl and Geber state that the parasite, echinococcus , not mentioned 
in dermatological treatises, is found in the human skin. Of 336 cases 
reported by Davaine, the parasite occurred thirty times in muscular and 
subcutaneous tissues, more often in women than in men. The softish, 
fluctuating tumors or vesicles produce a disagreeable sensation of ten¬ 
sion, and they undergo fatty or other metamorphosis after the death of 
the encapsulated parasite, that usually occurs in from one to two years. 
Exploration of the superficially seated fluctuating tumor, covered by 
unaltered integument, usually demonstrates its nature. 


Distoma Hepaticum. 

Kiichenmeister 1 reports three instances in which the embryos of the 
large liver-fluke were encapsulated in subcutaneous tissue. The tumors 
were painful or painless, and occurred on the head, trunk, and extrem¬ 
ities. 


Leptus. 

(Leptus Autumnalis, Harvest-bug, Mower’s Mite. 

Fr., Rouget.) 

The leptus (Figs. 102 and 103) is a minute, reddish or yellowish- 
red insect of the family of the Trombidce, visible to the naked eye, 
and found in summer and autumn clinging to bushes and grasses. It 
is found both in America and in Europe. It attacks man only after 
its accidental location upon the skin, where it perishes in the course 
of a few hours. In such situations, however, it induces considerable 
irritation, betrayed in erythematous, urticarial, papular, and even 
eczematous symptoms, accompanied by pruritus of various grades. 
The parts chiefly affected are the ankles, legs, arms, and feet. It may 
be seen in the skin as an orange-reddish or brick-reddish point, which 
represents often the body of the insect, its head being buried in the 
aperture of a follicle beneath. Examined after extraction, it is seen 
to have a relatively large cephalic extremity. It has a short, cylin¬ 
drical, and conical haustellum, composed of fused double maxillse; and 
two strong, hooked, five-jointed palpi, which can be rolled up. There 
are also two hatchet-like mandibles. It has a well-rounded or oval 
body 0.3558 mm. long and 0.32 mm. broad, provided with three pairs 
of legs. It is found particularly upon the lower limbs, but also upon 


1 Loc. cit. 


PARASITIC AFFECTIONS. 


773 


the scalp and every other part of the body. According to Duhring, 
children are especially liable to its encroachments. The disorder is 
relieved by the application of balsam of Peru in olive oil, carbolated 
oil, spirit of camphor, or other mild stimulant or parasiticide. 

There are several species of leptus ( leptus Americanus, leptus irritans) 
and other insects living on shrubs and grasses that, especially in the 
months of July and August, attack the human skin. 


Fig. 102. 


Fig. 103. 



Leptus autumnalis (harvest-bug). 


Fig. 104. 




Acarus hordei. 


The Acarus Hordei (krithoptes monunguiculosus ; Fig. 104) is named 
bv Wevl and Geber as the larva of a mite that annoys laborers in 
barley. It is yellowish-white, oblong or oval in form averaging 
0 022 mm in length. There is a protrudible tubular haustellum, 
enclosed by serrated mandibles. On each side are five-jointed palpi. 
There are four pairs of feet—two on the cephalo-thorax; two, abdom- 






774 


DISEASES OF THE SKIN. 


inal in situation—all articulated to the epimeres. The tarsus of the 
first part terminates in hooked claws; the others have haustellum disks 
on stems. Between the first and second pairs are swinging clubs, indi¬ 
cating the larval condition. 


Dipterous Larvae in and beneath the Human Skin. 

There is no dipterous insect peculiar to man alone, but a number of 
cases are on record where the ova of several species of oestrus have 
been deposited in the skin, and larvae subsequently been formed. The 
oestrus bovis , or gad-fly, is the most common of these. Usually, after 
the ova are deposited by the insect, a painful swelling occurs which 
may change from one point to another. When suppuration is induced, 
the larvae can be removed by pressure upon the boil. Walter Smith , 1 
of Dublin, has described such a case, where the swelling upon the 
ankle of a girl, twelve years old, moved to the elbow, and there dis¬ 
charged a white grub nearly an inch in length. Birdsall 2 described a 
specimen sent him from Gaboon, on the West Coast of Africa, in 
which two worms escaped from between the middle and the ring fingers 
of one hand; another workman having had a similar accident occur 
upon the leg. The fly whose ova had been deposited in these two 
cases was said to attack the gorilla; and members of a native tribe 
engaged in capturing these animals were reported as being very com¬ 
monly troubled in the same way. The worms sent to Dr. Birdsall 
were respectively one-fourth and one-half of an inch in length and 
about one-eighth of an inch in thickness. 

Fig. 105. Fig. 106. 

CL 



C d 


(Estrus: 'a, the larva, natural size; b, 
some of the segments seen under a lens, and 
showing the lines of minute projection ; c, 
and d, the terminal ends of the insect (after 
Abraham). 






Larvoe removed from the body of a child. 
Of the exact size, after several days in alco¬ 
hol ; a, as seen from side ; b, as seen from 
beneath. 


Abraham, of Dublin, also examined and reported upon a similar 
case, the specimen having been sent to the editor of the London Med¬ 
ical Press and Circular , from Porfsalon, Letterkenny. 

Several specimens illustrating these accidents have been sent to the 


See Report of Internat. Med. Congress, Arch, of Derm., January 
New York Medical Record, March 18, 1882, p. 298 






PARASITIC AFFECTIONS. 


775 


author. The larvae represented in the subjoined sketch (Fig. 106) 
were removed from the body of an infant in Nebraska, The musciace 
(flesh, house, stable, dung, and other flies) have unarmed maxillae, and 
are, therefore, unable to wound the uninjured skin. The pregnant 
female seeks, therefore, to deposit her ova where the larvae, equally 
unprovided with developed jaws, can most readily secure nutriment. 
Hence, open wounds and the tender skins of newborn infants when 
exposed in the summer season, are liable to become the depots ot 

such ova. / ,. , 

The ova of other species of muscidce and oestndce (according to 
Geber of the former, Lucilia Ccesar, in America; Stomoxis Calcdrans , 
in Africa; and Sarcophila Wohlfarti, in Russia; of the latter Derma- 
tobia Noxalis , Cuterebra , and Bypodermd ) are occasionally found m 
the skin and subcutaneous tissue. Severe cases are reported from 
Texas, where larvae have been expelled in great number from the 
nares after inhalation of chloroform. 


Ixodes. 

(Wood-tick.) 

Several species of tick are recognized, such as the Ixodes Humakus, 
Ixodes Bovis (cattle-tick), Ixodes Americans, Ixodes Margi- 
natus, Ixodes Unipunctatus, and Ixodes Ricrxus (wood-beetle), 
the last named being more common in Europe. In America they 
are found in wooded districts, especially those where pine- and hv- 
trees are growing. The female attacks the human skin bv thiusting 
into it her beak, armed on either side with a maxillo-labial projec¬ 
tion having recurved hooklets, the mandibles also presenting srmilar 
obstacles to the forcible extraction of the head After suction o the 
blood from beneath, the body of the tick swells to the size of t 
a pea or small bean, and may remain for several days n this potion. 
At such times the parasite may be mistaken for a small pedunc dated 
tumor Forcible attempts at extraction of the intruder are liable to 
detach the mandibles from the body, and thus leave them as the source 
of future irritation, and even disagreeable inflammatory symptoms, 
in the site of the punctured wound. By applying over, the tic 
drop of spirit of turpentine or benzine the head is spontaneously 
retracted and the body falls from its position. The soldiers on the 
olains of the United States accomplish the same end with the juice 
of tobacco The sensation produced at the moment of the insertion 
of the beak of the insect is said to be so tr,fling as often to pass 
unnoticed. 


776 


DISEASES OF THE SKIN. 


Pediculosis. 

(Lat. pediculus , a little foot.) 

(PHTHEIRrASIS, MORBUS PEDICULOSIS, LOUSINESS) 

Pediculosis is a contagious affection, characterized by the presence of lice upon the 
skin and the hairs, by the wounds inflicted by the parasite, and by the scratching 
which the resulting pruritus excites. 

Symptoms. Lice belong to the order Rhynchotta ; subdivision Par- 
asitce; family, Pediculidce. They are apterous, provided each with 
two eyes, and have an oral appendage capable of both inflicting wounds 
and producing suqtion. The lice infesting the human body are recog¬ 
nized as belonging to three varieties, those of the head, of the body, 
and of the pubes. Of the disorders to which they give rise it may be 
said in general that the lesions presented differ somewhat according to 
the region invaded, to the multiplicity of the intruders, and to the 
length of time during which their ravages have been inflicted. Such 
lesion'!, however, are those which have been already studied in connec¬ 
tion with eczema, urticaria, and the similar disorders resulting from 
external irritation. Their special peculiarities in pediculosis are owing 
solely to the nature of the exciting cause and to the mode of its opera¬ 
tion. 


Pediculosis Capillitii. 

(Parasite, the Head-louse.) 

Statistical frequency in America, 2.09. 

The head-louse (Fig. 107) is usually of a grayish color, but differs 
slightly with the hue of the hairs over the part which it frequents. Its 
head presents indistinctly the outline of a trefoil, 
fig. 107 . and is provided with two hairy antennae, each of 

five articulations, and with two eyes. Its thorax 
is relatively narrow, with six tracheal stigmata and 
three hairy legs on either side, the legs being pro 
vided with tarsal hooklets. The abdomen is 
divided into seven segments, defined by blackish 
indentations on either side. The males are fewer 
and smaller than the females, and they present 
upon the dorsum an anogenital orifice and a large 
conoidal penis and testes. The females are pro¬ 
vided with ovarias and with an anal aperture in 
pediculus capillitii—male the terminal abdominal segment. Coupling is per- 
(after kcchenmeister) formed with the male beneath. 

The ova or “ nits” (Fig. 108) are whitish bodies 
of oval contour, that are glued to the hairs by a cylindriform sheath 
of chitin, which completely encases the circumference of each filament. 
They are deposited in series, as the female traverses the hair from its 



PARASITIC AFFECTIONS. 


777 


insertion to its distal extremity, so that the oldest are in general the 
nearest to the scalp. The young escape from the ova in from three to 
eight days, and arrive at maturity in from 
eighteen to twenty days. A single female 
can, according to Kaposi, lay fifty eggs in six 
days, and thus in eight weeks have an entire 
progeny of five thousand lice. 

Head-lice usually limit their habitat to the 
scalp, though, rarely, in elderly men with long 
hair reaching to a full beard, they may encroach 
upon the latter. They infest every portion of 
the scalp, but find the region of the greatest 
protection upon the occiput. They are found 
upon children and adults of both sexes, but 
are best furnished with lodgement upon the 
scalps of girls and women covered by long and 
luxuriant hair. 

The lesions observed upon a scalp thus in¬ 
habited vary according to the age and vigor of 
the colony/ They are few or numerous, dis¬ 
crete or confluent pustules or bullse; the surfaces 
are excoriated by scratching and oozing with 
serum, pus, or blood; the crusts varying in 
character according to the nature of the desic¬ 
cated exudate and sebaceous matters. Often 
the picture presented is a conglomerate of an 
artificial eczema and seborrhea. 

The ova, or “ nits/' are usually abundant 
upon the hairs of an infested head, and will 
scarcely escape the attention of a close observer. 

They are not to be mistaken for the exfoliated, ova of the head-louse attached 
epithelial, and fatty plates seen in seborrhea “ n ^ r iyHnder°mriomatng 
sicca, disseminated among the hairs, and often a pi i ary filament ; &, chiti- 
perforated by hairy filaments, since the former nous sheath of ovum nearly 
are firmlv glued ‘in position, and resist the mature (after Kaposi). 
bristles of the hair-brush. The peculiarly 

nauseating odor also of the louse-infested, pustule- and crust-covered 
scalp is not to be confounded with that perceived in favus of the same 

region. . ,, . 

In exaggerated cases the post-cervical ganglia express, by their 
increase in size, the degree to which the local irritation has been 
pushed The itching is usually severe, and, in cases of long persist¬ 
ence in children, may produce the usual systemic symptoms of pro¬ 
longed local irritation. Children and patients of impoverished health 
and with poor hygienic surroundings are thought to exhibit the disease 
in severer grades than others; but this, if indeed a fact, must at least 
in part be due rather to the more favorable conditions for the develop¬ 
ment and multiplication of the parasites, which are presented in filth- 
accumulation and lack of cleanliness. In the public charities of large 
cities children are presented every week affected with pediculosis capil- 




778 


DISEASES OF THE SKIN . 


litii, who come from the very lowest social grades of the population 
and from the filthiest quarters. Among these children it cannot be 
observed that the general health of the patients is a factor of weight 
in the severity of the affection. 

The diagnosis of pediculosis capillitii is a matter of considerable 
importance, however simple of accomplishment, since many cases of 
supposed u pustular eczema of the scalp ” have vainly been treated by 
one physician with internal remedies addressed to the systemic vice 
assumed to be responsible for the disease which another has relieved 
after the discovery of a few liead-lice. The hairs should always be 
raised and separated, the scalp carefully be inspected, and the presence 
of any parasites, and especially ova or “ nits ” fastened to the hairs, be 
ascertained. Whether the lice have preceded or followed the eczema¬ 
tous state (and each of these conditions may be noted) is a matter of 
minor importance. Pustules about the nares and lips, especially of 
young girls, are often significant of pediculi of the occipital region, 
the lesions being due to picking and scratching the face under an 
impulse to relieve pruritic sensations of the scalp induced by the pres¬ 
ence there of lice. 

Treatment. The indications in the treatment of pediculosis capillitii 
are the destruction of all parasites with their ova, and the relief of the 
induced inflammatory condition of the scalp. Generally the removal 
of the former is followed by the spontaneous disappearance of the latter. 
For the destruction of the lice the most popular remedy in the United 
States certainly is petroleum (not kerosene), pure or with equal parts 
of the balsam of Peru, which gives it a more agreeable perfume, poured 
over the scalp in quantity sufficient to cover it without overflow upon 
the brow, temples, and neck. It should be rubbed in with a piece of 
white (undyed) flannel. At the end of from twelve to twenty-four 
hours the Jice are destroyed, and the ova are rendered incapable of 
development. This treatment is followed by a thorough shampoo with 
tincture of soap, or with toilet soap and hot water; after this operation 
the scalp may require a bland unguent, such as vaselin, or a small 
quantity of scented castor oil, either pure or in combination with spirits 
of wine. Kaposi employs petroleum as a parasiticide in combination 
with olive oil and balsam of Peru: five parts of the first, two and a 
half of the second, and one part of the third. Cutting the hair of 
women and children is quite unnecessary, as patience and gentleness 
with the use of the comb will finally disentangle the most matted 
masses after the lice have been destroyed. Other remedies are em¬ 
ployed locally for a similar purpose, of which the most popular are 
staphysagria, 1 drachm (4.) of the powdered seeds to the ounce (32.) 
of vaselin, but especially in decoction; tincture of cocculus indicus; 
carbolic acid in oil or water; sabadilla; the ethereal oils; and mercu¬ 
rials in ointment and solution, including the mercuric oleates. In 
cases where but a few parasites have found their way to the scalp, and 
that recently, nothing more is requisite than a careful use of the fine¬ 
toothed comb, scrubbing the scalp with a strongly scented alcoholic 
perfume, and a final bathing with soap and hot water. 

The ova adhering firmly to the hairs can be removed by soda on 


PARASITIC AFFECTIONS. 


779 


borax lotions, alcoholic solutions, or dilute acetic acid, which are sol¬ 
vents for the gluey material by which the u nits” are secured in place. 


Pediculosis Corporis. 

(Parasite, the Body-louse, Pediculus Vestimenti.) 


Fig. 109. 


Statistical frequency in America, 1.38. 

The parasite in this disorder inhabits exclusively the clothing worn 
next the body. In anatomical peculiarities it resembles the pediculus 
capillitii already described, being, however, larger in size, the females 
also larger than the males. The thorax is separated from the abdo¬ 
men, the latter being hairy, yellowish at the margins, and provided 
with eight segments. The eyes are black, and very prominent in both 
sexes; and the periods requisite for the maturing of the ova and young 
are those named respectively in connection with head-lice. In color 
they vary slightly from a dirty-white to a light grayisxi hue when 
undistended with blood. In the reverse of this last-named condition 
they may be recognized as having a dull reddish or a purplish color, 
when they are also more indolent in their movements. They measure 
from 2 to 3 mm. in length and 1 to 1.5 mm. in 
breadth. The female lays from seventy to eighty 
eggs, from which the young are produced in from 
three to eight days, and are capable of reproduction 
in a fortnight more. 

Thev inhabit the seams of undergarments, where 
their ova are also deposited; but in coarse woollen or 
flannel shirts they find sufficient shelter in the meshes 
of the material of Avhich the clothing is made; this 
they leave temporarily, solely for the purpose of ob¬ 
taining nutriment from the skin of their host, and 
hence are not recognized upon the free surface of the 
integument. Upon rapid removal of the clothing 
of an infested individual, a few may occasionally be 
encountered, hastily seeking a place of refuge, though 
this is rather the exception to the rule. It thus may 
happen that a louse-bitten patient may not exhibit 
the true source of his troubles to his physician after 
a recent and complete change of clothing. The greatei then t 
portance of being able to recognize the clinical featmes of the malady 
in the absence of the parasite. This recognition is comparatively easy 
to one who has made himself familiar with the symptoms of the disorder 
The manner in which the louse is enabled to supply itself with the 
blood of man has carefully been studied by Swammerdam, Landois 
Schiodte, and Tilbury Fox. The last-named author has summarized 
the observations of the others, and the results he gives may briefly be 

described as follows: , . , . i i 

Swammerdam’s original view that the louse is not provided with 



Pediculus corporis- 
female (after 

KtJCHENMEISTER). 



780 


DISEASES OF THE SKIN. 


mandibles by which it can inflict a wound, but with an haustellum by 
which the blood is sucked up to the head of the parasite, is confirmed 
by Schjodte. This observer, examining the head of the louse from 
behind with reflected light, discovered that the parts of the head 
resembling mandibles in appearance were really situated beneath its 
skin. He applied to the integument lice which had been previously 
starved, and watched each as, with retracted limbs, arched back, and 
head inclined obliquely downward, it repeatedly projected forward and 
retracted through the extreme end of its head a “ small, dark, narrow 
organ/ 7 by which it was firmly held in place. A triangular blood-red 
point soon became visible in front of the eyes, rapidly and alternately 
contracting and dilating, and followed by energetic peristalsis of the 
gastro-intestinal tract. If the head then be cut off in front of the 
eyes, and the haustellum carefully be extracted, the latter can be recog¬ 
nized as a brownish protrusion, armed with terminal recurved hooks, 
from which depends a delicate membranous tube varying in length. 
“It seems that the mouth is like that in the rhyncotta generally, but 
differs in the circumstance that the labium is capable of being retracted 
into the upper part of the head, and has a fold in it when so retracted. 
In order to strengthen this part, a flat band of chitin is placed on the 
under surface; and it is thinner in the middle in order that it may bend 
and fold a little when the skin is not extended by the lower lip. The 
latter consists of two hard lateral pieces, of which the fore-ends are 
united by a membrane, so that they form a tube, of which the internal 
covering is a continuation of the elastic membrane on the top of the 
head. Inside its orifice are a number of small hooks, which assume 
different positions according to the degree of the protrusion; and if 
this be pushed to its highest point, they form a collar of hooks curved 
backward like barbs. The pediculus first inserts its labium into a 
sweat-pore and protrudes the lip. When the hook gets hold of the 
parts around, then the first pair of setse (the real mandibles trans¬ 
formed) are protruded., and these are toward the point invested by 
membrane so as to form a closed tube, from which again is exserted a 
second pair of setae or maxillae, which form a tube and end in four 
small lobes placed crosswise. The whole forms a membranous tube, 
along the walls of which retiform mandibles and maxillae are placed 
as long, narrow bands of chitin. This tube can be lengthened or short¬ 
ened at pleasure. ” 

This explanation of the mode in which the louse attacks the skin is 
probably true of each of the varieties which infest the human body. 
Fox well suggests that the invaded follicle, after the withdrawal of 
the haustellum, becomes the seat of a circumscribed hemorrhage. None 
of the anatomical peculiarities described above will, however, com¬ 
pletely explain the characteristic pruritus of pediculosis corporis, for 
it can scarcely be questioned that it is not merely at the moment of 
attack or penetration that the suffering of the victim is greatest. The 
pruritic condition of the louse-wound persists, indeed usually attains 
its maximum, after the withdrawal of the pediculus, and is without 
doubt greater than that awakened by merely mechanical puncture of 
the epidermis. Anyone who will compare the skin of a louse-infested 


PARASITIC AFFECTIONS. 


781 


patient with one who has been subjected to the acupuncture process 
employed among the lower classes of Germans, and by them known 
as “ baunscheidtismus,” can convince himself of this fact. 

The lesions seen on the skin thus invaded are proportioned, as in 
pediculosis capillitii, to the size and age of the colony of parasites. 
Excoriations, usually linear, occasionally circumscribed, varying in 
depth and length, radiate irregularly from each louse-wound, and they 
may be commingled with minute papules, transitory wheals, or, in 
rare, exaggerated cases, with the typical signs of diffuse eczema. All 
are produced by scratching in order to relieve the pruritus. Crusts, 
often composed of desiccated blood, rarely of serum or pus, minute 
and capping the wounded follicle, or linear and coextensive with the 
excoriations produced by the scratching, are generally conspicuous. 
In older cases these lesions are followed by the usual sequel, pigmenta¬ 
tion, the latter being a partial indication of lousiness which has long 
been tolerated. 

In America it is rare to note the severe and intense forms of the 
malady, resulting from long-continued neglect of the skin, that occur 
in Germany. In these cases follow: dermatitis, rupioid crusts, furun¬ 
cles, abscesses, carbuncles, and ulcers, resulting in serious implication 
of the skin which may persist for weeks after the clothing has. been 
freed from lice, and finally leave a deep-tinted, diffuse pigmentation of 
the skin-surface, suggesting that of the negro or of the patient affected 
with Addison’s disease. 

The diagnosis is a matter of importance. Patients will visit physi¬ 
cians, claiming that they have suffered from a u humor of the blood, 
who have been swallowing drugs for a long period of time, in the vain 
hope of obtaining relief, with lice, at the very moment of uttering the 
complaint, crawling over their persons. Even those of good social 
position and habits of cleanliness will occasionally suffer after acci¬ 
dental contacts in the tram car or railway-carriage, the hotel, the 
theatre, or other places of public resort. There are certain points to 
be carefuly noted in this connection. Excoriations over the nucha, 
about the shoulders, loin«, buttocks, and external faces of the thighs, 
all visible at the same time, are highly suspicious symptoms; as an 
eczema, when equally diffuse, is sure to be accompanied at some point 
by perfectly classical features ; and generalized pruritus is exceedingly 
rare, its localized varieties concerning chiefly the regions about the 
mucous outlets of the body. There is a picture highly suggestive o 
pediculosis expo-ed to the eye when the trunk of an infested patient 
is viewed from behind. The lesions are more discrete, more irregularly 
distributed, and more intermingled with long scratch-marks, reaching, 
for example, quite over the point of one shoulder, than in most disorders 
with which pediculosis vestimenti could be confounded. Here and 
there minute blood-specks tell a significant tale. When clinical pa¬ 
tients exhibit syphilodermata interspersed among characteristic lesions 
of pediculosis corporis, the students themselves in such cases can ordi¬ 
narily point out the particular symptoms referable to the separate 

disorders present. , . , 

In private practice it is usually advisable, for obvious reasons, to 


782 


DISEASES OF THE SKIN. 


secure the corpus delicti before informing the sufferer of the nature of 
his or her complaint. In the case of male patients it is well to take a 
position in the rear, and when the underclothing is drawn well up from 
the shoulders a careful scrutiny of it may be made while the applicant 
for relief supposes that attention is directed instead to his person. 

The treatment of the disorder concerns largely the clothing. The 
latter requires immersion in boiling water, or it may be wrapped in 
paper and subjected to a high temperature in an oven (160°-175° F.), 
sufficient to destroy the lice and their ova. In case of recurrence of 
the malady the clothing is to be again subjected to the same process. 
Usually the resulting irritation of the skin promptly subsides. When 
several members of one family suffer all clothing worn must be sub¬ 
jected to similar treatment. If the skin has been unusually tormented 
by scratching, warm alkaline baths will afford some comfort, and they 
may be followed by a bland unguent or by one of the dusting-powders. 
For immediate use, before the clothing can be rid of the intruders, a 
parasiticide ointment may be ordered as recommended by Duhring, 
prepared by adding 2 drachms (8.) of freshly powdered staphysagria 
to the ounce (32.) of hot lard, strained and cooled. The surface of 
the skin may also be anointed with carbolic acid dissolved in oil or in 
water. 


Pediculosis Pubis. 


Fig. 110. 


(Parasite, the Pcjbic Louse, Crab-louse. Fr., Morpion.) 

Statistical frequency in America, 3.52. 

In this disorder the genital region is chiefly involved, though in 
exceptional cases all the hairy portions of the skin may be invaded, 

including the eyebrows, the eyelashes, 
the axillae, and the moustache and beard, 
the hairy chest, and the hairy legs of the 
male. The body of the pubic louse (Fig. 
110) is smaller than either of those de¬ 
scribed above. Its head is also attached 
more closely to its thorax, having a shape 
which is compared with that of a violin. 
The thorax is not distinctly separated 
from the abdomen, and of the six stout 
legs with which the louse is provided, 
the second and third pair are conspicu¬ 
ously powerful, and armed with relatively 
large hooks at the tarsal extremity. The 
resemblance of the latter to the claws of 
a crab has given to this creature the com¬ 
mon name of “ crab-louse.” The lateral 
abdominal indentations are much less distinct than in the other varieties; 
and the blackish marginal marks of the body-and head-lice are here 
scarcely apparent. The abdomen is also much elongated, having a 



Pediculus pubis (after Schmarda). 



PARASITIC AFFECTIONS. 


783 


more rounded contour. The pubic louse is provided on its lateral 
borders with eight short conical feet, terminating in bristles. It is 
also distinguished from the others of its family by the length of its 
anal bristles, and by the peculiar shield-shaped carapace which covers 
nearly one-half of the dorsum. The male is from 0.8 to 1 mm. long, 
and from 0.5 to 0.7 mm. in width, being thus from 1 to 1.5 mm. 
smaller than the female. 

The pubic louse is much more inactive than the others, and does 
not ordinarily escape its pursuer. It buries its head deeply in a fol¬ 
licular orifice, and steadies itself in this position, where it may remain 
for some time, by grasping the adjacent hairs with its short and pow¬ 
erful claws. A moderate degree of force is required for its dislodge- 
ment from this favorite position, and when removed its grasp of the 
hair to which it clings is so firm that the latter usually slides for its 
entire length through the claw of the louse. Occasionally it may be 
found creeping over the skin or clinging to hairs at a distance from 
the skin-surface. The pyriform ova are smaller than those of the head- 
louse, though having a similar color, and are, like the latter, attached 
to the hairs by a firm chitinous glue. 

Pubic lice are usually acquired during the contacts incidental to the 
sexual act; are, hence, more frequently encountered among adults; but 
may, without question, more rarely be transmitted mediately by occu¬ 
pation of beds and covering which have been used by infested persons. 
They are thus, though very rarely, found in children of both sexes. 

The lesions induced are those produced by the wounds inflicted by 
the parasites and by constant scratching, though these are rarely severe. 
In a few cases, one may see a severe eczema follow the ravages of the 
lice, but in such event the complication is chiefly owing to unneces¬ 
sarily severe self-treatment of the disorder, patients being often mor¬ 
bidly anxious in their efforts to rid themselves of the pests. 

The diagnosis of pediculosis pubis is between eczema and pruritus 
genitalium. The disease last named is, in both sexes, accompanied by 
helling, and that often of intense grade; but when this is diffuse and 
symmetrical in distribution it is not limited particularly to the hairy 
parts. Eczema of the genitals is not often produced by parasites of 
that region, and it may readily be recognized by its characteristic fea¬ 
tures. "Both disorders are often, indeed, limited to symmetrical patches 
upon the side of the scrotum or one labium. The discovery of the 
parasite, however, in pediculosis pubis is always essential, and requires 
merelv careful inspection and a good light. The lice may be recognized 
either at or near the point of implantation of the hairs, which also dis¬ 
play ova except in very recently infested individuals. The reddish 
excrement of the parasites mingled with scratch-marks and excoriated 
papules of small size may also be observed. Patients are often made 
aware of their condition by a sensation of crawling over the parts. 
Scratching of the pubic region in adults of both sexes should awaken 

some suspicion of the disorder. r 

Treatment. The disease is commonly treated by the topical applica¬ 
tion of mercurial ointment, which is a disagreeable and rather filthy 
medication for this locality. The 10 per cent, oleate may be substi- 


784 


DISEASES OF THE SKIN. 


tuted for it, or, even preferably, corrosive sublimate in solution, 
from 3 to 4 grains (0.2-0.266) to the ounce (32.). Petroleum and 
olive oil with the balsam of Peru, in the proportions given above in 
connection with the subject of pediculosis capillitii, is an effective 
combination. Slaphysagria, carbolic acid, cocculus indicus, or one of 
the other substances used in the disorders occasioned by the animal para¬ 
sites, may be substituted if desired. It is usually better to defer bath¬ 
ing until the remedy selected for the destruction of the lice has been 
applied on several occasions, after which a warm water-and-soap ablu¬ 
tion will commonly end the trouble. It is needless to clip the pubic 
hairs. Should an eczematous disorder remain, it requires appropriate 
treatment, including hot bathing and the blander lotions and unguents. 

Vagabond’s Disease. This is a term given to the condition of 
the skin recognized among tramps, inmates of poorhouses, and the 
filthy and neglected in general. The skin of such persons is often 
densely indurated, harsh, dry, and deeply pigmented, in consequence 
of much scratching and a consequent hyperemia. This condition is 
produced chiefly by phtheiriasis; but is often a resultant of the incur¬ 
sions of several parasites, including those of the bed and of the clothing. 
It is also a consequence of persistent neglect of the bath. 

Pediculi and Acari transferred to Man from the Lower 
Animals rarely thrive in such uncongenial soil, but as a matter of 
exception they occasionally survive such transfer. Thus, Goldsmith, 1 
of Vermont, reports the case of a woman affected with intense pru¬ 
ritus, who after sweating profusely observed numbers of pigeon- or 
lien-lice emerging from the sweat-pores. Megnin 2 reports similar cases 
under the title Prurigo Dermanyssique, the dermanyssus avium , or 
gallince, being the acarus infesting domesticated fowls. The disorder is 
said to be at times epidemic in the vicinity of aviaries and pigeon- 
cotes, but is always of trifling severity. 


Cimex Lectularius. 

(Acanthia Lectularia, Bugs, or Bedbugs.) 

Strictly speaking, the bedbug is not a parasite of man, but finds its 
congenial habitat in the bed, bedding, and bed-covering, and the walls 
and floors of apartments occupied by persons of both sexes and all ages. 
It infests also furniture, including chairs, sofas, and the cushions of 
seats occupied in public vehicles and hotels. From the cracks, crevices, 
seams, folds, or other protected points where it has found lodgement, 
it emerges usually at night, for the purpose of securing its nutriment 
in the blood of its victims. It is a pest as ancient as the day in which 
Dioscorides wrote. 

1 Louisville Medical News. December 31,1881, p. 320. 

2 Les parasites et les maladies parasitaires chez l’homme, les animaux domestiques, etc., Paris,. 


PARASITIC AFFECTIONS. 


785 


This insect has a rusty or reddish color, this differing slightly accord¬ 
ing as it is or is not distended with blood. It is an apterous member 
of the order of CiMiciDiE. It is provided with a blunt-pointed head, 
broadly attached to the thorax ; two long slender antennae ; and a 
three-jointed haustellum capable of projection and retraction beneath 
the head. There are three pairs of long slender legs by which it 
is enabled to accomplish rapid movements. The abdomen is broad 
and flattened, and oval in shape, with nine segments. The parasite 
emits a disgusting odor, which is much more distinct when it is 
crushed. 

The wound inflicted by this bug is accomplished with or without the 
consciousness of its victim, who in the former case is made aware of 
a transitory prick or sting. Soon after, decidedly pruritic, burning, or 
stinging sensations are experienced, and the wound becomes the seat 
of an urticarial wheal. The lesion then, examined soon after the inflic¬ 
tion of the wound, is seen to be small pea- to bean-sized, and in the 
form of an elevated and circumscribed “ button ” or papulo-tubercle, 
either whitish in the centre, or exhibiting there also the hyperemia 
which distinguishes its peripheral zone. After the lesion has begun to 
subside and lose its acute features, which may not occur tor several 
hours if it be irritated by rubbing or scratching, a minute reddish 
puncture may be seen marking the original site of the wound. 

The lesions are usually multiple even when but a single assailant 
has been present, the insect taking apparent delight in obtaining its 
nutriment from several distinct points upon one surface. In this way 
at times its course upon the integument may for a short distance be 
traced. In cases where the pests are numerous, as m hlthy dwellings, 
prisons, ships, and barracks, and when infants have been attacked, the 
resulting eruption is often greatly masked by the scratching and resu 
ing excoriations of the skin-surface. In this way vesicles, pustules, 
crusts, purpuric blotches, and even skin-infiltrations may be found, 
instead of the rosy or light-reddish typical wheals of recent cases in 

patients with fair clean skins. , 

The diagnosis is a matter of importance, and upon it may hang a 
professional reputation. Physicians are often consulted respecting 
these lesions by patients who believe themselves to be suffering from 
“ humors,” exanthemata, and even from syphilis. The insect attacks 
the parts of the body to which access is easy as the patient sits or re¬ 
clines on the back or side, including the buttocks, the thighs, the shoul 
ders, the loins, and the neck, in that order of frequency, ra le 
largely than the legs, much less frequently the scalp, the face, and the 
genitalia. The eruption is not to be confounded with urticaria ab 
ingestis, which is more apt to be symmetrical in disposition. 

Treatment. The eruption is best relieved by the topical application 
of spirit of camphor, alcohol, weak carbolated lotions, or solutions of 
boric acid, 1 drachm to the pint. Untreated, ^disappears sponto- 
neously when the source of the disorder is removed. 1 he most effec¬ 
tive treatment is by prophylaxis, with soap, cortosive sublimate and 
hot water, of all accessories of the dwelling-house inhabited by the 
insects. Once discovered to be present, infested furniture should be 

50 


786 


DISEASES OF THE SKIN. 


scrubbed in all its crevices with a saturated solution of corrosive subli¬ 
mate in alcohol, and bed-clothing be immersed in boiling water. 

Other insects which may persistently or only occasionally attack 
the human skin are: the mosquito and gnat (Culex Pipiens); midges 
(Simulia) ; bees (Apes Mellifer^i); and wasps (Vespidje). 


Culex Pipiens, etc. 

Mosquitoes, midges, etc., produce, by their bites or stings, various 
cutaneous lesions, including urticarial wheals, papules, ecchymoses, 
and in rare cases even ecchymomata. The lesions produced by the flea 
are found more often on the legs, the neck, or other covered portions 
of the body. Those of the midge and mosquito are seen on the face, 
the hands, aud exposed parts; though, when numerous and voracious, 
these insects will penetrate the clothing for the purpose of obtaining 
blood. Severe eruptive lesions are often seen in America on the faces 
and extremities of infants and children exposed during the night to 
the incursions of these marauders. The skin symptoms are usually 
treated locally by aqua ammonise or the spirit of camphor. 

The bodies of immigrants newly arrived during the summer season 
in America, from countries where the mosquito is either rare or does 
not exist, often present singular and even formidable evidences of the 
attacks of these insects. The skin, totally unaccustomed to such 
depredations and quite unprotected, will often be found greatly swol¬ 
len, and of a light reddish hue suggestive of erysipelas. Here and 
there bullae are conspicuous, which add to the resemblance to the last- 
named disease. The features, in consequence of the tumefaction, 
vesiculation, aud papulation, may be so swollen as to present a con¬ 
spicuous deformity; and the forearms, and even the arms, seem greatly 
increased in size from the same cause. The feet and legs also may, 
in the unconsciousness of sleep, be exposed in hot weather to the 
depredations of these marauders, and iu the same way the back, the 
buttocks, and, rarely, even the genitalia may present the same signs 
of inflammation. The matter of chief moment is the correct diagnosis 
of such cases, as many patients seeking relief under such circumstances 
have been treated for disorders with which they were not affected. 


Protozoa and Sporozoa. 

The relations sustained by some forms of protozoa to diseases of the 
skin and of other organs in man are as yet undetermined. The so- 
called psorosperms observed by a number of investigators in Darier’s 
disease, carcinoma, molluscum fibrosum, Paget’s disease, herpes zoster, 
and varicella have clearly been demonstrated to be bodies produced by 
cell-transformation. It is well known, however, that the livers and 
other organs of rabbits and of some other animals often contain cocci- 
dhe (a sub-class of sporozoa), and several instances of peculiar forms 


PARASITIC AFFECTIONS. 


787 


of disease in man have been reported in which protozoa were satis¬ 
factorily demonstrated. Psorospermosis of internal organs of man is 
described by Osier 1 and by Blanchard. 2 

Two cases of protozoan infection of the skin and other organs are 
reported by Rixford and Gilchrist. In one case the course of the 
disease was chronic, and the cutaneous lesions were amost identical 
clinically and histologically with some of the verrucous types of tuber¬ 
culosis. The patient died finally of a general infection which was in 
every way similar to a tubercular infection, but careful search failed 
to reveal tubercle-bacilli, while protozoa were found in great numbers 
in lesions of the skin and of other organs. Successful, though not 
entirely satisfactory, inoculations were made on rabbits and dogs. 
The second case reported by these observers closely resembled the first, 
except that the process was comparatively acute and the protozoa were 
present in larger numbers. The protozoa and the histology of the 
lesions in these two cases have been carefully and exhaustively studied 
by Gilchrist, who has published the results of his labors in the Johns 
Hopkins Hospital Reports (vol. i., 1896), including in the report his 
study of Duhring’s “ Case of Blastomycetic Dermatitis in Man,” and 
a reference to Wernicke’s case. 3 This report contains also “ Com¬ 
parisons of two Varieties of Protozoa and the Blastomyces with the 
so-called Parasites in certain Lesions of the Skin,” with a full bibli¬ 
ography. 

1 Principles and Practice of Medicine, p. 1080, 2d edition. New York, 1895. 

2 Bouchard’s Traite de Pathologie generate, Tome ii. p. 682. Paris, 1896. 

3 Ueber einen Protozoonbefund bei Mycosis Fungoides (?) Centralblatt f. Prakt. u. Parasitenk., 
1892. Bd. xii. 














































































. 

































INDEX 


A CANTHIA lectularia, 784 
t\. Acantholysis bullosa, 402 
Acanthosis nigricans, 447 
Acarus folliculorum, 124, 767 
hordei, 773 

scabiei, 757, 758, 759, 762 
Achromia, 489 
unguium, 518 
Acne, 369 

diagnosis of, 374 
etiology of, 373 
pathology of, 374 
prognosis of, 381 
symptoms of, 369 
treatment of, 37 5 
albida, 127 
artificialis, 370 
atrophica, 370, 387 
cachecticorum, 371 
cancrdidale , 543 
contagious, 373 
cornea, 372 
cornee, 372 
decalvante, 508 
disseminata, 372 
frontalis, 387 

group of tuberculoses, 577 
hypertrophica, 370 
indurata, 371 
keloidienne, 511 
keratosa, 372 
necrotica, 387, 577 
papulosa, 371 
parasitica, 372 
ponctuee, 122 
punctata, 371 
pustulosa, 371 
rodens, 387 
rosacea, 382. 

diagnosis of, 384 
etiology of, 383 
pathology of, 383 
prognosis of, 386 
symptoms of, 382 
treatment of, 384 
rosee, 382 

scrofulosorum, 371 
sebacea, 109 
sebacee cornee , 422 
sebacee fluente, 110 
varioliforme,' 428 
varioiiformis, 387 
diagnosis of, 388 
etiology of, 387 


| Acne varioliformis, pathology of, 388 
symptoms of, 387 
treatment of, 388 
vulgaris, 372 
Acne, 369 
Acrochordon, 530 
Acrodynia, 207 
Acromegaly, 479 
Actinomycose, 747 
Actinomycosis of the skin, 747 
diagnosis of, 748 
etiology of, 748 
pathology of, 748 
prognosis of, 7 49 
symptoms of, 748 
treatment of, 749 
Acute circumscribed oedema, 172 
of the skin, 465 

diagnosis of, 465 
treatment of, 466 
idiopathic oedema, 172 
non-inflammatory oedema, 172 
purulent oedema, 222 
i Addison’s disease, 414 
Adenoma, 543 

of coil-glands, 545 
of sebaceous glands, 543 
diagnosis of, 544 
etiology of, 544 
pathology of, 544 
treatment of, 544 
acquired, benign, 543 
congenital, benign, 543 
malignant, 544 
of sweat-glands, 545 
Adenomes sebaces , 543 

cancroidaux, 543 
Aden ulcer, 221 

Adjectives employed in dermatology, oy 
Ainhum, 598 
i Aktinomykose, 747 
i Albinism, 489 

complete, 489 
partial, 489 
! Albinismus, 489 

etiology of, 490 
symptoms of, 489 
I Albinoes, 489 
Albugo, 518 
Aleppo evil, 220 
Aliments, indigestible, 173 
Alopecia, 496 

pathology of, 498 
symptoms of, 496 






790 


INDEX. 


Alopecia, treatment of, 498 
areata, 501 

diagnosis of, 505 
etiology of, 503 
pathology of, 504 
prognosis of, 508 
symptoms of, 501 
treatment of, 505 
false, 509 
cicatricial, 509 

Alopeeies cieatricielles innominees , 508 
Alopecia circumscripta, 501 
congenital, 496 
follicularis, 508 
furfuracea, 500 
neurotica, 507 
premature, 497 
pre-senile, 497 
senile, 497 
Alphos, 254 
Alveolar sarcoma, 691 
Analgesic paralysis, with whitlow, 475 
Anatomical tubercle, 570 
Anatomy of the skin, 17 
Anderson’s dusting-powder, 160 
Anesthesia, 706 
Angiokeratoma, 426 
etiology of, 426 
pathology of, 426 
prognosis of, 427 
symptoms of, 426 
treatment of, 427 
Angioma, 550 

diagnosis of, 552 
etiology of, 553 
pathology of, 552, 553 
prognosis of, 555 
symptoms of, 550 
treatment of, 552, 554 
cavernosum, 553 
infective, 556 

pigmentosum et atrophicum, 560 
serpiginosum, 556 
diagnosis of, 557 
etiology of, 556 
pathology of, 556 
symptoms of, 556 
treatment of, 557 
Angiomyoma, 549 
Angioneurotic oedema, 172, 465 
Anguillulidse, 771 
Anhidrosis, 104 
Anidrose, 104 
Anidrosis, 104 

treatment of, 104 

Anomalous discoloration of the skin, etc. 

415 

Anthemata, 59 
Anthrax, 212 
maligna, 215 

diagnosis of, 217 
etiology of, 216 
pathology of, 216 
prognosis of, 217 
symptoms of, 215 
treatment of, 217 


; Anthrax simplex, 212 * 
diagnosis of, 214 
etiology of, 213 
pathology of, 214 
prognosis of, 215 
symptoms of, 212 
treatment of, 214 
Antimony, 78 
I Apes melliferse, 786 
j Aplasie moniliforme intermittente, 515 
i Appliances, surgical, 90 
Area Celsi, 501 
Johnstoni, 501 
j Argyria, 414 
Arrectores pilorum, 34 
Arsenic, 75 
Arteries of skin, 27 
I Arthritic diathesis, 66 
Asiatic pill, 75 
Aspergillus, 754 
Asteatose, 121 
j Asteatosis, 121 

prognosis of. 121 
symptoms of, 121 
treatment of, 121 
! Atheroma, 129 

Atrophia maculosa et striata, 520 
pilorum propria, 512 
senilis, 519 
unguis, 517 
Atrophies, 488 
of hair, 496 
of nail, 517 
of pigment, 488 
Atrophodermia neuriticum, 521 
pigmentosum, 560 
Atrophy, diffuse, idiopathic, 521 
partial, idiopathic, 519 
Aussatz, 656 
Autographism, 169 


B ACILLOGENOUS dermatoses, 208 
sycosis, 223 
Baldness, 496 
Bald tinea tonsurans, 731 
Barbadoes leg, 476 
Barber’s itch, 737 
Bartfinne, 223 
Baths, 80 
Beaded hairs, 515 
Bedbugs, 784 
Bees, 786 

Beigel’s disease, 517 

papilloma area elevatum, 445 
Bellamy’s iodized phenol, 330 
Benign cystic epithelioma, 687 
Biskra bouton, 220 
“ Black-head,” 122 
Black measles, 146 
Blaschenjlechte, 238 
Blasenausschlag, 390 
Blastomyces, 787 
Blastomycetic dermatitis, 787 
Blattern, 142 
Blebs, 55 




INDEX. 


791 


Bleeding stigmata, 707 
Blood-vessels of skin, 27 
Bloody sweat, 108 
Blushing, 155 
Blutschwdre , 208 
Boatman’s ringworm, 744 
Boba, 485 
Boil, Delhi, 220 
oriental, 220 
Boils, 208 

Bouton d’Amboine, 485 
Bowditch Island ringworm, 743 
Bromidrosis, 105 
etiology of, 105 
pathology of, 105 
symptoms of, 105 
treatment of, 105 
Brother ulcer, 487 
Bubo, 485 

of chancroid, 653 
Buccal psoriasis, 547 
Bucnemia tropica, 476 
Bug, harvest, 772 
Bugs, 784 
Bulb of hair, 38 
Bullse, 55 

hemorrhagica, 404 
Bullous eruption, peculiar, 249 
Burmese ringworm, 743 
Burns, 184 

treatment of, 184 

pACHEXIE pachydermique, 709 
U Cacotrophia folliculorum, 419 
Callosities, 432 

of the hands with unusual complica¬ 
tions, 433 
Calvities, 496 
Calx sulphurata, 77 
Camphor chloral, 178 
Cancer, 669 . 

en cuirasse, 684 

prognosis of, 686 
epithelial, 670 
fibrous, 684 
hard, 684 
lenticular, 684 
of the connective tissue, 684 
of the extremities, 675 
of the genital organs, 675 
of the head, 674 
of the lower lip, 675 
of the mucous surfaces, 676 
scirrhous, 684 
Cancroide, 670 
Cancroid ulcer, 670 
Canities, 493 

etiology of, 494 
pathology of, 495 
symptoms of, 493 
treatment of, 495 
Canker rash, 137 
Carbolic acid, 78 
Carboncle, 212 
Carbuncle, 212 


Carbunculus, 212 
Carbunkel, 212 
Carcinoma, 669 
cutis, 687 

diagnosis of, 691 
etiology of, 690 
pathology of, 690 
prognosis of, 692 
treatment of, 692 
epitheliale, 670 
melanotic, 686 
pigmented, 686 
tuberose, 686 
Cascadoe, 743 
Cattle-tick, 775 
Caustics, 89 

Cellidome epithelial eruptif, 687 
epithelial eruptif kystique, 545 
Chalazodermia, 532 
Chancre, 601 

Hunterian, 602 
non-infecting, 651 
simple, 651 
soft, 651 
Chancrelle, 651 
Chancroid, 651 

diagnosis of, 654 
etiology of, 654 
pathology of, 654 
prognosis of, 654 
symptoms of, 651 
treatment of, 655 
Charbon, 215 
Cheiro-pompholyx, 252 
I Chicken-pox, 150 
| Chigoe, 768 
.- I Chilblains, 157, 185 
Chloasma, 412, 750 

diagnosis of, 415 
etiology of, 413 
pathology of, 415 
prognosis of, 417 
symptoms of, 412 
treatment of, 416 
cachecticorum, 413 
from arsenic, 415 
uterinum, 413 

Chloral-camphor, 89, 178, 701 
C hoc-en-retour, 174 
Chorionitis, 468 
Chromidrose , 106 
Chromidrosis, 106 
Chronic erysipelas, 201 

pustular dermatitis, etc., 197 
Cicatrices, 58 
Cicatrix, 527 

diagnosis of, 529 
pathology of, 529 
treatment of, 529 
hypertrophic, 526 
Cimichhe, 785 

Circumscribed and purulent oedema, 4oo 
scleroderma, 469 
Class I., 97 

11., 132 

111., 404 









792 


INDEX. 


Class IV., 411 

V. , 488 

VI. , 524 

VII. , 696 

VIII. , 711 
Classification, 93 

American Dermatological Associa¬ 
tion’s, 95 
Auspitz’s, 94 
Bronson’s, 94 
Hebra’s, 93 
Clavus, 435 

treatment of, 435 
Clou, 208 

de Biskra, 220 

Coccogenous dermatoses, 208 
sycosis, 223 
Coco, 485 
Cod-liver oil, 76 
Coil-duct cysts, 103 
-glands, 42 
“Cold-sores,” 238 
Colles’s law, 639 
Collodion, 87 

Colloid metamorphosis of skin, 542 
diagnosis of, 543 
etiology of, 543 
pathology of, 543 
treatment of, 543 
milium, 542 
Collo'idome miliaire, 542 
Comedo, 122 

diagnosis of, 124 
etiology of, 123 
pathology of, 124 
prognosis of, 127 
symptoms of, 122 
treatment of, 125 
extractor, 92 

Concretions upon hair-shafts, 516 
Condyloma, 439, 615 
latum, 614 
Condylomata, 626 
Congelatio, 185 
Congenital alopecia, 496 

dystrophy of nails and hair, 456 
fibro-sebaceous disease, 131 
keratoma of palms and soles, 424 
Conglomerative pustular perifolliculitis, 
237 

etiology of, 237 
pathology of, 237 
treatment of, 237 
Consecutive lesions, 55 
Contagious acne, 373 
Copaiba, 78 
Copper-nose, 482 
Cor, 435 
Corium, 21 
Corn, 435 

Come de la peau, 436 
Cornu cutaneum, 436 

etiology of, 438 
pathology of, 438 
prognosis of, 438 
symptoms of, 436 


j Cornu cutaneum, treatment of, 438 
Corpuscles of Meissner, 32 
of Vater, 30 
of Wagner, 32 
Pacinian, 30 
tactile, 32 

Cortical substance of hair, 39 
Cosme paste, 682 
I Cosmolin, 81 
j Counter-irritation, 90 
Couperose, 382 
Cow-pox, 151 
Crab-louse, 782 
-yaws, 4fc6 
| Crapea.ux, 486 
Craw-craw, 771 
Creosote, 78 
Cretinoid oedema, 709 
Crustse, 56 
Crusts, 56 
' Culex pipiens, 786 
; Curettes, 91 

! Cutaneous hemorrhages, 404 
psorospermosis, 676 
Cuterebra, 775 
Cuticle, 24 
Cutis anserina, 34 
I Cutisector, 91 
! Cutis vera, 21 
Cyanhidrosis, 107 
Cystadenomes epitheliaux benins. 545 
Cysticercus cellulosse cutis, 771 
Cystic lymphangioma, 558 
Cysts of the coil-duct, 103 
multiple dermoid, 131 
sebaceous, rare consequences of disease 
of, 131 


D actylitis syphilitica. 575 

tuberculous, 575 
j Dandruff, 109 
I Darier’s disease, 422 
I Dartre , 238 

humide, 230 
Dartrous diathesis, 66 
Decolor ization des ongles, 518 
Deep epithelioma. 671 
Deficiency of hair, 496 
Defluvium capillorum, 496 
Delhi boil, 220 

treatment of, 221 
Demodex folliculorum, 767 
Depilatories, 463 
Derma, 21 

Dermanyssus avium, 784 
gallinse, 784 
Dermatalgia, 705 
diagnosis of, 706 
prognosis of, 706 
treatment of, 706 
Dermatite, 179 
Dermatitis, 179 
calorica, 183 

treatment of, 184 
contusiformis, 165 



INDEX. 


793 


Dermatitis, exfoliative infantum, 275 
exfoliativa, 273, 276 
diagnosis of, 275 
etiology of, 275 
pathology of, 275 
prognosis of, 275 
symptoms of, 27 4 
treatment of, 275 
fatal, pemphigus-like, 249 
gangrenosa, 177 
infantum, 198 

etiology of, 198 
pathology of, 198 
prognosis of, 198 
treatment of, 198 
herpetiformis, 249, 400 
etiology of, 251 
pathology of, 251 
prognosis of, 252 
symptoms of, 249 
treatment of, 251 
medicamentosa, 186 

rashes induced by acids, 187 
aconite, 187 
antipyrin, etc., 187 
arsenic, 187 
belladonna, 188 
bromin, etc., 188 
cannabis indica, 189 
chloral, 189 
cod-liver oil, 189 
condurango, 190 
copaiba and cubebs, 190 
digitalis, 190 
iodin, etc , 190 
jaborandi and pilocarpin, 192 
mercury, 192 
opium, etc., 192 
petroleum, 193 
phosphorus. 193 
podophyllin, 193 
potassium chlorate, 193 
quinin, etc , 193 
salicylic acid, etc., 193 
santonin, 194 
sodium benzoate, 194 
biborate, 194 
stramonium, 194 
strychnin, 194 
tanacetum, 194 
tar and turpentine, 194 
papillaris capillitii, 372, 511 
repens, 365 
seborrhoica, 301, 359 
traumatica, 180 
venenata, 180. 

Dermatobia noxalis, 775 
Dermatolysis, 532 
Deimatomycosis furfuiacea, 750 
Dermatosclerosis, 468 
Dermatosis Kaposi, 560 

of scrofulous subjects, 576 
Dermoid cysts, 131 

Desquamative scarlatiniform erythema, 
162 

Destructive agents, 89 


Dhabie’s itch, 744 
Diabetides , 300 
genitales, 345 

Diachylon ointment, Hebra, 325 
Diagnosis, 67 

Dietary articles producing hives, 173 
Diet in eczema, 317 
Diffuse idiopathic atrophy, 521 
symmetrical scleroderma, 468 
Digit! mortui, 199, 592, 708 
Dipterous larvae, 774 
Diseases due to animal parasites, 757 
of glands, 97 
of the skin, 97 

Disorders due to vegetable parasites, 712 
Dissection-tubercle, 570 
-wounds, 219 

Disseminated ringworm, 731 
Distoma hepaticum, 772 
Donda ndugu, 487 
Drug eruptions, 186 

diagnosis of, 195 
Dyes, 495 
Dysidrosis, 252 

Dystrophy of nail and hair, congenital, 
456 


E CCHYMOMATA, 404 
Ecchymoses, 405 
Echinococcus, 772 
Ecthyma. 234 

diagnosis of, 236 
etiology of, 235 
pathology of, 235 
prognosis of, 236 
symptoms of, 234 
treatment of, 236 
gangrenous infantile, 198 
Eczema, 293 

diagnosis of, 307 
etiology of, 303 
pathology of, 306 
prognosis of, 332 
symptoms of, 293 
treatment of, 314 
acute, 302 
ani, 347 
aurium, 340 
barbae, 342 
capitis, 333 
chronic. 303 

clinical types and varieties of, 294 

crurale, 351 

diabeticorum, 300 

erythematosum, 294 

faciei, 335 

fissum, 300 

folliculorum, 301 

genitalium, 344 

impetiginodes, 298 

intertrigo, 300 

labiorum, 337 

lichenodes, 295 

local varieties of, 333 

madidans, 299 






INDEX. 


794 


Eczema mammae, 349 
manuum, 353 
marginatum, 301, 723 
membrorum, 351 
narium, 339 
palpebrarum, 341 
papulosum, 295 
parasiticum, 301, 359 
pedum, 353 
pustulosum, 298 
rhagadiforme, 300 
rubrum, 299 
sclerosum, 300 
seborrhoicum, 301, 359 
diagnosis of, 364 
etiology of, 362 
pathology of, 363 
symptoms of, 360 
treatment of, 364 
solare, 357 
squamosum, 299 
tuberculatum, 692 
tuberculous, 300, 578 
of anus and anal region, 347 
treatment of, 348 
of beard, 342 
of ears, 340 

diagnosis of, 340 
treatment of, 340 
of eyelids, *41 

diagnosis of, 342 
of face, 335 
of feet, 353 
of genitals. 344 

diagnosis of, 346 
etiology of, 345 
treatment of, 346 
of hands, 353 
of hands and feet, 353 
diagnosis of, 354 
etiology of, 354 
treatment of, 355 
of lips, 337 

diagnosis of, 338 
of nails, 356 

of nipple and breast of women 349 
treatment of, 350 
of nostrils. 339 

diagnosis of, 339 
treatment of, 339 
of scalp, 333 

diagnosis of, 334 
treatment of, 334 
of superior and inferior extremities, 
351 

diagnosis of, 351 
treatment of, 352 
of tropics, 357 

etiology of, 357 
prognosis of, 358 
treatment of, 357 
of umbilicus, 350 
umbilici, 350 
unguium, 356 
universal, 358 
verrucosum, 300 


Eczema vesiculosum, 296 
Eczematoid epitheliomatosis of the nipple, 
676 

j Eiterpusteln, 234 
Electrolysis, 90 
Elementary lesions, 51 
Elephantiasis, 476 

diagnosis of, 481 
etiology of, 479 
pathology of, 480 
prognosis of, 482 
symptoms of, 476 
treatment of, 481 
Arabum. 476 
Grecorum, 656 
lymphangiectatica, 557 
nevoid, 479 
tuberculosa cutis, 572 
Elephant-leg, 476 

| Endemic degeneration of the bones of the 
foot, 744 
Ephelis, 411 
Ephidrosis, 97 
tincta, 106 

Epidemic erythema, 207 

exfoliative dermatitis, 281 
skin disease, 281 
Epidermis, 24 

' Epidermolysis bullosa hereditaria, 402 
Epilating-forceps, 91 
Epithelial cancer, 670 
Epithelialkrebs , 670 
Epithelioma, 670 

diagnosis of, 680 
etiology of, 678 
pathology of, 679 
prognosis of, 684 
treatment of, 681 
adenoides cysticum, 545 
benign cystic, 687 
contagiosum, 428 
deep, 671 
discoid, 670 
papillary, 672 
superficial, 670 
tubercular, 671 
i Epitrichial layer, 27 
Equinia, 217 

etiology of, 218 
pathology of, 218 
prognosis of, 219 
symptoms of, 217 
treatment of, 219 
I Erbgrind, 712 
Erectores pilorum, 34 
Ergot, 77 
Erysipel , 199 
Erysipelas, 199 

diagnosis of, 203 
etiology of, 202 
pathology of, 202 
prognosis of, 205 
symptoms of, 199 
treatment of, 203 
ambulans, 200 
chronic, 201 






INDEX. 


795 


Erysipelas chronicum, 207 
Lombardy, 206 
Erysipele, 199 
Erysipeloid, 205 
Erythanthema syphiliticum, 625 
Erythanthemata, 59 
Erythema, 155 

diagnosis of, 156 
treatment of, 156 
ab igne, 157 
annulare, 164 
bullosum, 166 
caloricum, 156 
circinatum, 164 
epidemic, 207 

exsudativum multiforme, 163 
figuratum, 164 
fugax, 157 

gangrenosum, 157, 197 
hyperemicum, 155 
induratum, 164, 578 
symptoms of, 578 
treatment of, 57 9 
intertrigo, 158 

diagnosis of, 159 
etiology of, 159 
symptoms of, 158 
treatment of, 160 
iris, 164, 401 
leve, 157 
migrans, 205 
marginatum, 165 
multiforme. 163 

diagnosis of, 167 
etiology of, 166 
pathology of, 167 
prognosis of, 163 
symptoms of, 164 
treatment of, 168 
nodosum, 165 
papulatum, 165 
papulosum, 165 
paratrimma, 157 
pernio, 157 

diagnosis of, 158 
treatment of, 158 


punctatum, 162 
scarlatiniforme, 162 
diagnosis of, 163 
etiology of, 163 
symptoms of, 162 
treatment of, 163 
simplex, 155 
symptomatic, 161 
traumaticum, 156 
tuberculatum, 165 
tuberculosum, 165 
urticatum, 165 
variolous, 142 
venenatum, 157 
vesiculosum, 166 
Erythematous syphilide, 608 
Ery theme, 155 
centrifuge , 590 
indure des serofuleux , 578 
infectueux , 162 


Ery theme noueux, 165 

papulo- tuber culeux, 163 
scarlatiniforme desquamatif, 162 
scarlatino'ide , 162 
Erythrasma, 754 
diagnosis of, 756 
etiology of, 755 
pathology of, 755 
prognosis of, 756 
symptoms of, 754 
treatment of, 756 
Esthiomene , 570 
Etiology, general, 61 
Exanthemata, 59, 132 
Excoriations, 57 

Expansions and fissures of hairs, 515 

External treatment, 79 

Eyelids, spontaneous gangrene of, 198 

F ATAL pemphigus-like dermatitis, 249 
Fat-columns, 45 
Fatty substances, 81 
Favic onychomycosis, 714 
Favus, 712 

of nail, 714 
Feigned eruptions, 196 
Feigwarze, 626 ^ 

Fetid sweat, 105 
Feuerguertel , 242 
Fibroid of skin, recurrent, 690 
Fibroma, 530 

diagnosis of, 534 
etiology of, 533 
pathology of, 533 
prognosis of, 534 
symptoms of, 530 
treatment of, 534 
Fibroma fungoides, 692 
molluscum, 530 
pendulum, 532 

Fibromatosis tuberculosa cutis, 572 
Fibromyoma, 549 
Fibro-sarcoma, 691 

-sebaceous disease, congenital, 131 
Fibrous cancer, 684 
Ficosis, 223 
Filaria medinensis, 769 
diagnosis of, 770 
etiology of, 769 
pathology of, 769 
prognosis of, 770 
symptoms of, 76 
treatment of, 77 
sanguinis hominis, 479 
Fischschuppenausschlag, 449 
Fish-oil, 88 

-skin disease. 449 
Fissures, 57 
Flea, 768 
Fleckenmal , 445 
Folliculitis barbse, 223 
Folliculites et perifolliculites decalvantes , 508 
destmctives du follicule pileux, 508 
Folliculitis decal vans, 508 
exulcerous, 403 






796 


INDEX . 


Folliculitis, of the tuberculous and scro 
fulous, 577 

Forceps, epilating, 91 
grappling, 91 
Fragilitas crinium, 513 
Frambesia, 485 

diagnosis of, 486 
etiology of, 486 
pathology of, 486 
prognosis of, 486 
symptoms of, 485 
treatment of, 486 
Framosi, 485 
Freckles, 157, 411 
French measles, 136 
Frost itch, 7Q4 
Fumigation, 644 
Fungus, dry, 747, 748 
foot of India, 744 
Furuncles, diagnosis of, 211 
etiology of, 209 
pathology of, 210 
prognosis of, 212 
treatment of, 211 
Furunculus, 208 

symptoms of, 208 


G ad-fly, 774 

Gafsa button, 220 
Gale, 757 

Gangrene foudroyante, 222 

Gangrene, multiple, in adults, 198 

of skin, multiple disseminated, 198 
of the skin, 197 

spontaneous, of the eyelids, 198 
symmetrical, 162 

Gangrenous infantile ecthyma, 198 
Gefdssmal, 550 
General diagnosis, 67 
etiology, 61 
prognosis, 72 
symptomatology, 50 
therapeutics, 73 

Generalized primary non-melanotic sar¬ 
coma, 689 

German measles, 136 
Giant ringworm, 744 
“Giant swelling,” 172 
wheals” 53, 170 
Glands, coil-, 42 
diseases of, 97 
of Tyson, 41 
sebaceous, 40 

diseases of, 109 
sudoriparous, 42 
sweat-, 42 

diseases of, 97 
“Glossy fingers,” 472 
skin,” 521 
Glycerin, 81 
Glyco-gelatins, 82 
Glycosuric xanthoma, 541 
Gommes scrofuleuses, 575 
scrofnlo-tuberculeuses, 575 
“Goose-flesh,” 34 


Granular layer, 26 
Granuloma fungoides, 692 
sarcomatodes, 692 
Greenish sweating, 107 
Grutum, 127 
Guaiacol, 78 
Gune, 743 

Gutartiges epithelioma, 545 
Gutta rosea, 382, 482 


H AARSACKMILBE. 767 
Hair, atrophies of, 496 
-dyes, 495 
-follicles, 36 
Hairiness, 458 

Hair-shafts, concretions upon, 516 
-sheaths, 36 
Hairs, 35 

beaded, 515 
“checkered,” 515 
expansions and fissures of, 515 
nodes of, 515 
Harlequin fetus, 451 
Ilarnschweiss, 108 
Harvest-bug, 772 
Hautentzundung, 179 
Hautjinne, 389 
Hauthorn, 436 
Hautrothe, 155 
Hautsclerem, 468 
Health-resorts, 79 
Hebra’s diachylon ointment, 325 
Helmerich’s ointment modified, 766 
Hematidrosis, 108 
Hemiatrophia facialis, 472 
Hemizona, 242 
Hemophilia, 408 
Hemorrhages, 404 
Henle’s layer, 38 
Herpes, 238 

symptoms of, 238 
treatment of, 240 
‘‘black,” 243 

circinatus bullosus, 249, 400 
desquamans, 743 
facialis, 238 
febrilis, 238 

gestationis, 242, 249, 400 
iris, 164, 241, 249, 401 
phlyctenodes, 249 
progenitalis, 239 
tonsurans, 729 

desquamatif, 743 
maculosus, 272 
zoster, 242 

diagnosis of, 247 
etiology of, 245 
pathology of, 246 
prognosis of, 249 
symptoms of, 242 
treatment of, 248 
I Herpetic diathesis, 66 
Herpetiform hydroa, 400 
Hide-bound skin, 468 
l Hidradenitis, etiology of, 403 





INDEX. 


797 


Hidradenitis, pathology of, 403 
suppurativa, 403 

symptoms of, 403 
treatment of, 403 
Hirsuties, 458 
Hives, 169 
Hoariness, 493 
Honeycomb ringworm, 713 
Horn, 436 
-pox, 146 

Horny layer of skin, 27 
Horse-pox, 373 
Huhnerauge , 435 
Hunterian chancre, 602 
Huxley’s layer, 38 
Hyaloma, 542 
Hyalom der Haul, 542 
Hybrid measles, 136 
Hydradenitis destruens suppurativa, 403 
Hydradenome eruptif, 545, 687 
Hydroa, 249, 400 
estivale, 401 
bidleux , 401 
herpetiform, 400 
puerorum, 401 
vacciniforme, 401 

pathology of, ^02 
treatment of. 402 
■ vesiculeux, 165, 401 
Hydrocystoma, 103 
diagnosis of, 104 
etiology of, 103 
pathology of, 1<’3 
symptoms of, 103 
treatment of, 104 
Hydrosis, 97 
Hyperesthesia, 696 
Hyperhidrosis, 97 
Hyperidrosis, 97 

etiology of, 98 
pathology of, 99 
prognosis of, 100 
symptoms of, 97 
treatment of, 99 
oleosa. 110 

Hyperkeratosis striata et folliculans, 4: 
Hypertrichosis, 458 

diagnosis of, 458 
etiology of, 461 
treatment of, 461 
neurotica 460 
Hypertrophies, 411 

of connective tissue, 464 
of epidermal and papillary layers, 
of hair, 458 
of pigment, 411 
Hyphogenous sycosis, 223 
Hypoderma, 775. 

Hypodermatic injection, 90 
Hysteria and skin lesions, 196 


[CHTHYOL, 77, 88 
1 Ichthyose, 449 
Ichthyosis, 449 

diagnosis of, 454 


Ichthyosis, etiology of, 452 
pathology of, 453 
prognosis of, 455 
symptoms of, 449 
treatment of, 454 
Ichthyosis congenita, 451 
follicularis, 422 
hystrix, 449 
linguae, 452, 547 
palmaris et plantaris, 424 
sebacea, 113 
simplex, 449 

Idiopathic multiple pigment-sarcoma, 689 
Idrosis, 97 
ignes sacer, 242 
Impetigo, 230 

diagnosis of, 231 
etiology of, 231 
pathology of, 231 
symptoms of, 230 
treatment of, 232 
contagiosa, 232 

diagnosis of, 234 
etiology of, 233 
pathology of, 233 
symptoms of, 232 
treatment of, 234 
eczematodes, 298 
figurata, 299 
herpetiformis, 389 
diagnosis of, 389 
etiology of, 389 
pathology of, 389 
prognosis of, 389 
symptoms of, 388 
treatment of, 389 
| Infective angioma, 556 
Inflammation of the lips and mouth, 709 
of the skin, 132 

I Inflammatory fungoid neoplasm, 692 
j Injection, hypodermatic, 90 
| Insects, 786 

Instruments used in skin diseases, 91 
Internal treatment, 74 
Inunction, 643 

!7 ! Iodin and compounds, 76 
Iodism, 648 
Iodized phenol, 330 
i Itch, barber’s, 737 
Dhabie’s. 744 
prairie, 704 
j Ittiosi, 449. 

Ivy-poisoning, 182 
118 treatment of, 183 
Ixodes, 775 

Americanus, 775 
bo vis, 775 
humanis, 775 
marginatus, 775 
ricinus, 775 
unipunctatus, 775 


TABOR AND I, 77 ^ 
J Jacob’s ulcer, 670 
Jequirity, 89 






INDEX. 


798 


Jigger, 768 
Juice-spaces, 29 


K AHLHEIT, 496 
Kaolin, 82 
Keloid, 524 

diagnosis of, 527 
etiology of, 526 
pathology of, 526 
prognosis of, 527 
symptoms of, 524 
treatment of, 527 
-acne, 372, 511 
cicatricial, 526 
Keratoangioma, 426 

Keratodermia palmaris et plantaris, 424 
diagnosis of, 425 
symptoms of, 424 
treatment of, 425 
Keratoma, 432 
Keratosis, 418 

follicularis, 422 
contagiosa, 427 
diagnosis of, 424 
etiology of, 423 
pathology of, 423 
symptoms of, 422 
treatment of, 424 
pilaris, 418 

diagnosis of, 420 
etiology of, 419 
pathology of, 419 
symptoms of, 418 
treatment of, 420 
senilis, 421 
Kerion Celsi, 736 
Kleienflechte, 750 
Kratze, 757 
Kraurosis vulvse, 523 
Krithoptes monunguiculosus, 773 
Kruslenflechte , 230 
Kuhpocken , 151 
Kupferjinne , 382 
Kupferrose, 382 


T AFA Tokelau, 743 
-Li Land scurvy, 407 
Lanolin, 86 
La perleche, 756 
La Peta, 743 

Large acuminate papular syphiloderm, 
613 

pustular syphiloderm, 619 
flat papular syphiloderm, 614 
pustular syphiloderm, 620 
La Rosa, 206 
La Rose, 199 
Lassar’s paste, 82, 331 
Lax skin, 532 
Lee’s lamp, 645 
Lenticular cancer, 684 
Lentigo, 411 

etiology of, 411 
pathology of, 412 


Lentigo, symptoms of, 411 
treatment of, 412 
Leontiasis, 656 
Lepothrix, 516 
Lepra, 254, 656 

diagnosis of, 667 
etiology of, 663 
pathology of, 665 
prognosis of, 669 
symptoms of, 650 
treatment of, 668 
anesthetica, 660 
Arabum, 656 
fungifera, 485 
maculosa, 659 
Lepre, 656 
Leprosy, 656 

nodulated, 657 
tuberculated, 657 
tuberosa, 657 
Leptus, 772 

Americanus, 773 
autumnalis, 772 
irritans, 773 
J Lesions, consecutive, 55 
elementary, 51 
Leucasmus, 489 
Leucoderma, 489 
acquired, 490 
complete congenital, 489 
j Leucokeratosis buccal is, 547 
diagnosis of, 548 
etiology of, 548 
pathology of, 548 
prognosis of, 549 
symptoms of, 547 
treatment of, 548 
Leucoplakia buccalis, 257, 547 ( 
Leucoplasia, 547 
Lichen eczematodes, 295 
exudativus ruber, 283 
pilaris, 418 

of Crocker, 420 
planus, 287 

diagnosis of, 292 
etiology of, 291 
pathology of, 291 
prognosis of, 293 
symptoms of, 287 
treatment of. 292 
psoriasis, 279, 283 
ruber, 283 

diagnosis of, 286 
etiology of, 286 
pathology of, 286 
prognosis of, 287 
symptoms of, 283 
treatment of, 287 
acuminatus, 283 
moniliformis, 285 
planus, 284 
scrofulosorum, 576 
simplex, 295 
tropicus, 357 
urticatus, 170 
Lichenification, 290 





INDEX. 


799 


Liodermia cum melanosi et telangiectasia, 
560 

Liquor carbonis detergens, 702 
picis alkalinus, 327 
Lister’s borax salve, 350 
Lithemic diathesis, 66 
Livedo, 162 
Local asphyxia, 199 
Lombardy erysipelas, 206 
leprosy, 206 
Louse, body, "79 
crab, 782 
head, 776 
pubic, 782 
Lousiness, 776 
Lucilia Csesar, 775 
Lumberman’s itch, 704 
Lumpy-jaw, 747 
Lunula, 49 
Lupani, 485 

Lupoid sycosis, 225, 509 
Lupus crustosus, 567 

demisdereux de la langue , 569 
elephantiaticus, 566 
elevatus, 566 
erythematodes, 590 
erythematosus, 579, 590 
diagnosis of, 595 
etiology of, 594 
pathology of, 594 
prognosis of, 598 
symptoms of, 590 
treatment of, 590 
follicular, 593 
telangiectatic, 591 
exfoliativus, 566 
exuberans, 566, 567 
fibrosus, 566 
fungoides, 567 
fungosus, 567 
gangrenosus, 567 
hypertrophicus, 566 
keloides, 567 
maculosus, 565 
nodosus, 566 
non-exedens, 566, 590 
non-ulcerosus, 566 
cedematosus, 566 
of the ears, 567 
of the extremities, 568 
of the face, 567 
of the genital region, 567 
organs in women, 570 
of the mucous membrane, 569 
of the trunk, 567 
papillosus, 566 
planus, 565 
profundus, 567 
psoriasiforme, 566 
-psoriasis, 566 
rodens, 567 
rupioides, 567 
sclereux y 566, 571 
sclerosus, 566, 571 
sebaceus, 590 
serpiginosus, 567 


Lupus, superticialis, 567, 590 
tuberculatus, 566 
tumidus, 566 
vegetans, 567 

vulgaris, 568. See Tuberculosis. 
vulgaris erythemaloide, 595 
Lymphadenie cutanee, 692 
Lymphangiectasis, 557 
Lymphangioma, 557 
Lymphangioma circumscriptum, 558 
etiology of, 559 
pathology of, 559 
symptoms of, 558 
treatment of, 559 
cystic, 558 
simple, 557 

tuberosum multiplex, 546 
Lymphangiomyoma, 549 
Lymphatic vessels of the skin, 28 
Lymph-scrotum, 479 
Lymphodermia perniciosa, 692 
Lympho-sarcoma, 691 


M acrochilia, 558 

Macroglossia, 558 
Maculae, 51 
Macules, 51 
Madura foot, 744 
Majee’s dad, 744 
Malabar ulcer, 221 
Mai de los Pintos, 756 
Malignant papillary dermatitis, 349, 676 
pustule, 215 

Mai perforant du pied , 433 
Mai Roxo, 206 
Malum perforans pedis, 433 
Marsden’s paste, 682 
Maseru , 132 

Massering ball, 92, 125, 381 
Matrix of nail, 48 

McCall Anderson’s dusting-powder, 160 
Measles, 132 
black, 146 
French, 136 
German, 136 
hybrid, 136 
Medicinal rashes, 186 
Medullary substance of hair, 39 
Medullated nerve-fibres, 30 
Meibomian glands, 41 
Meissner, corpuscles of, 32 
Melanoderma, 413 
Melano-sarcoma, 687 
Melanosis lenticularis progressiva, 447, 
560 

Melanotic carcinoma, 686 
whitlow, 688 
Mellitagra, 299 
Mentagra, 223 
parasitica, 737 
Mercury, 89 

by fumigation, 644 
by injection, 645 
by inunction, 643 
in skin diseases, 76 






INDEX. 


800 


Microsporon Audouini, 719 
furfur, 751 
minutissimum, 755 
Midges, 786 

Miliaria crystallina, 100 
diagnosis of, 102 
etiology of, 101 
pathology of, 101 
symptoms of, 100 
treatment of, 102 
Miliaire scrofuleuse, 387 
Miliary fever, 102 
Milium, 127 

diagnosis of, 128 
etiology of, 127 
pathology of, 128 
prognosis of, 129 
symptoms of, 127 
treatment of, 128 
Milk crust, 112 
Mineral springs, 79 
Mitesser, 122 
Moist warts, 439 
Molluscum contagiosum. 428 
epitheliale, 428 

diagnosis of, 431 
etiology of, 429 
pathology of, 430 
prognosis of, 432 
symptoms of, 428 
treatment of, 432 
pendulum, 530 
sebaceum, 428 
verrucosum, 428 
Monilethrix, 515 
Moniliform hairs, 515 
Morbilli, 132 

diagnosis of, 135 
pathology of, 134 
prognosis of, 135 
symptoms of, 132 
treatment of, 135 

Morbus maculosus Werlhoffii, 407 
pediculosivS, 776 
pedis entophyticus, 744 
Morphea. 469 
Morpion, 782 
Morvan’s disease, 475 

diagnosis of, 476 
etiology of, 475 
pathology of, 475 
symptoms of, 475 
treatment of, 476 
Mothers’ marks, 552 
Mower’s mite, 772 
Mucous layer, 25 
patches, 626 
“Mulberry marks,” 552 
Multiple benign cystic epithelioma, 545 

tumor-like new-growth of skin, 
522 

cutaneous tumors accompanied by in¬ 
tense pruritus, 443 
dermoid cysts, 131 
gangrene in adults, 198 
Muscidae, 775 


Muscles of skin, 34 
Muscular fibres, non-striated, 34 
striated, 34 
Mycetoma, 744 

diagnosis of, 747 
etiology of, 746 
pathology of, 746 
symptoms of, 745 
treatment of, 747 
Mycosis fungoides, 692 

diagnosis of, 695 
etiology of, 694 
pathology of, 694 
prognosis of, 695 
symptoms of, 692 
treatment of, 695 
microsporina, 750 
Myoma, 549 

diagnosis of, 550 
treatment of, 550 
dartoic, 549 
simple, 549 
telangiectodes, 549 
Myringomycosis, 754 
Myxedema, 709 

diagnosis of, 710 
etiology of, 710 
pathology of, 710 
symptoms of, 709 
treatment of, 711 
Myxo-sarcoma, 691 


ATAIL-FOLD, 49 
| li -plate, 48 
I Nails, 47 
Naphtol, 88 
N atal sore, ^220 
Needles, 91 
Nerves of skin, 29 
Nervous papillae, 24 
Nesseljieber, 169 
Nesselsuch, 169 
Nettle-rash, 169 
Neuroma, 534 

symptoms of, 534 
Neuropathic plica, 460 
Neuroses, 696 
Nevi pigmentosi, 460 
pilosi, 460 

Nevus lipomatodes, 445 
mollusciformis, 445 
pigmentosus, 445 

pathology of, 446 
treatment of, 446 
pilosus, 445 
spilus, 445 
verrucosus, 445 
Nevoid elephantiasis, 479 
Nevus araneus, 551 
flammeus, 550 
lupus, 556 
sanguineus, 550 
vasculosus, 550 
] New-growths, 524 

of connective tissue, 524 





INDEX. 


801 


New-growths, of muscular tissue, 549 
of vessels, 550 
Nigua, 768 

Nodose swellings of shafts of hairs, 515 
Nodositas crinium, 514 
Noli-me-tangere, 670 
Non-medullated nerve-fibres, 29 
-parasitic sycosis, 223 
Norwegian itch, 762 


O DORS of the skin, 47 

(Edema, acute circumscribed, 172, 
idiopathic, 172 
purulent, 222 
angioneurotic, 465 
cretinoid, 709 
neonatorum, 464 
diagnosis of, 465 
etiology of, 465 
pathology of, 465 
prognosis of, 465 
symptoms of, 465 
treatment of, 465 
(Eil de perdrix , 435 
(Estridse, 775 
(Estrus bovis, 774 
Ohio scratches, 704 
Oils, 81 
Oleates, 87 
Onychatrophie, 517 
Onychauxis, 455 
etiology of, 457 
pathology of, 457 
symptoms of, 455 
treatment of, 457 
Onychia, 455 

syphilitic, 456 
Onychogryphosis, 456 
Onychomycosis, 724 
favic, 714 

Operations on the skin, 90 
minor, 90 
surgical, 90 
Oriental boil, 220 
lotion, 379 
Osmidrosis, 105 
Over-fatty soaps, 81 


PACHYDERMATOCELE, 532 
I Pachydermia, 476 

lymphangiectatica, 557 
Pacinian corpuscles, 30 
Paget’s disease of the nipple and areola, 
349, 676 
diagnosis of, 677 
pathology of, 677 
prognosis of, 678 
treatment of, 678 
Palmar and plantar syphilides, 616 
Panaris analgesique, 475 
Panniculus adiposus, 20 
Papillae of skin, 22 
Papillary epithelioma, 672 
layer, 22 


Papilloma, 445 

area elevatum, 445 
Papulae, 52 
Papules, 52 

Papulose filarienne, 771 
I Parakeratosis scutularis, 428 
variegata, 283 
Parangi, 485, 487 
Parasitae, 776 
| Parasitic affections, 711 
Parasitdre Bartfinne , 737 
Paronychia, 455 
5 j Pars papillaris, 22 
reticularis, 22 
| Partial albinism, 489 

idiopathic atrophy, 519 
Paste, Lassar, 82 
-pencils, 86 
Pastes, 82 

gelatin, 84 
glycerin, 84 

Peculiar skin eruption of pregnancy, 249 
Pediculi and acari transferred from man 
to animals, 784 
Pediculidse, 776 
Pediculosis, 776 

symptoms of, 776 
capillitii, 776 

diagnosis of, 778 
symptoms of, 776 
treatment of, 778 
corporis, 779 

diagnosis of, 781 
symptoms of, 779 
treatment of, 782 
pubis, 782 

diagnosis of, 783 
symptoms of, 782 
treatment of, 783 
Pelade , 501 

Peliosis rheumatica, 406 
Pellagra, 206 
Pemphigus, 249, 390 

diagnosis of, 398 
etiology of, 396 
pathology of, 397 
prognosis of, 400 
symptoms of, 391 
treatment of, 399 
acute, 391 

acutus contagiosus adultorum, 232 
aigu prurigineux , 249 
benignus, 392 
chronic, 391 
circinatus, 249, 392 
compose, 249 
disseminatus, 392 
foliaceus, 393 
gangrenosus, 198 
hemorrhagicus, 392 
hystericus, 242 
like dermatitis, 249 
malignus, 392 
neonatorum, 394 
of young girls, 395 
j prurigineux, 249 


51 










802 


INDEX. 


Pemphigus pruriginosus, 392, 400 
solitarius, 392 
vegetans, 395 

treatment of, 396 
virgin um, 395 
vulgaris, 391 

Perforating ulcer of the foot, 433 
diagnosis of, 435 
pathology of, 434 
prognosis of, 435 
symptoms of, 433 
treatment of, 435 

Perifolliculitis, conglomerative pustular, 
237 

Periodic swelling, 172 
Pernio, 157, 185 
Peruvian wart, 485, 488 
Petechiae, 405 
Petite verole, 142 
Phagadena tropica, 221 
Phenol-camphor, 89, 701 
Phlegmona diffusa, 222 

prognosis of, 223 
treatment of, 223 
Phlegmon, progressive, 205 
Phosphorus, 78 
Phtheiriasis, 776 
Phymata, 54 

Physiology of the skin, 17 
Pian, 485 

dartre , 485 
gratelle , 486 
ruboide , 511 
Piedra, 516 
Pied tabetique , 709 
Pigmentary mole, 445 
syphilide, 611 
Pigment-atrophies, 488 
Pigmented carcinoma, 686 
Pigment of skin. 33 
Pili annulati, 515 
Pilocarpin, 77 
Pinta disease, 756 
Pityriasis capitis, 500 
circinate, 272 

and marginate, 724 
circine et margine, 172 
maculata et circinata, 27 2 
diagnosis of, 273 
etiology of, 273 
pathology of, 273 
symptoms, of, 272 
treatment of, 273 
pilaris, 418 
rosea, 272 
rosee de Gibert, 272 
rubra, 276 

diagnosis of, 278 
etiology of, 278 
pathology of, 278 
prognosis of, 279 
symptoms of, 276 
treatment of, 279 
aigu, 276 
pilaire, 279 
pilaris, 279 


I Pityriasis rubra pilaris, diagnosis of, 281 
etiology of, 280 
pathology of, 281 
prognosis of, 281 
symptoms of, 280 
treatment of, 281 
versicolor, 750 
Pityrodes capillitii, 500 
| Plaques jaunvires des paupieres, 536 
muqueuses, 615, 626 
Plaster-mulls, 85 
Plasters, 85 
Pleximeter, 92 
Plica, neuropathic, 460 
Polonica, 460 
Pocken, 142 
I Podelcoma, 744 
Poils acddentels, 458 
Poison ivy, 182 
Poliosis, 493 

circumscripta acquisita, 491 
Poliothrix, 493 
Polyidrosis, 97 
Polypapilloma tropica, 485 
j Polytrichia. 458 
Pomphi, 52 
Pompholyx, 252, 390 
diagnosis of, 253 
pathology of, 253 
symptoms of, 252 
treatment of, 253 
Pores of skin, 43 
Porrigo contagiosa, 232 
decalvans, 501 
favosa, 712 
larvalis, 232, 279 
Post-mortem tubercle, 570 
Poultices, 87 
Powders, 85 
Prairie itch, 704, 764 

prognosis of, 705 
treatment of, 705 

Precautions in management of tinea favosa 
and tinea trichophina, 742 
Pregnancy, eruptions in, 249 
Premature alopecia, 497 
Presen ile alopecia, 497 
Prickle-cells, 26 
Prickle-layer, 25 
Prickly heat, 357 
Primary melanotic sarcoma, 687 
non-melanotic sarcoma, 688 
Prognosis, general, 72 
Progressive phlegmon, 205 
Protozoa, 786 
Protozoan infection, 787 
Prurigo, 366 

diagnosis of, 368 
etiology of, 367 
pathology of, 368 
prognosis of, 369 
symptoms of, 366 
treatment of, 369 
agria, 366 
dermanyssique , 784 
ferox, 366 





INDEX. 


803 


Prurigo hyemalis, 704 
mitis, 366 
summer, 402 
winter, 704 
Pruritus, 696 

diagnosis of, 699 
etiology of, 698 
pathology of, 699 
prognosis of, 703 
symptoms of, 696 
treatment of, 700 
ani, 698 
genitalium, 698 
hiemalis, 704 
narium, 697 
palmar et plantar, 698 
Pseudo-pelade , 509 
Psora, 254 
Psoriasis, 254 

diagnosis of, 260 
etiology of, 257 
pathology of, 258 
prognosis of, 271 
symptoms of, 254 
treatment of, 263 
buccal, 547 
circinata, 254 
diffusa, 254 
figurata, 254 
guttata, 254 
gyrata, 254 
linguae, 257, 547 
nummularis, 254 
orbicularis, 254 
punctata, 254 

Psorospermose folliculaire vegetante, 422 

Psorospermosis, 422 
Ptomains, 219 
Ptyalism, 647 
Pulex irritans, 768 
penetrans, 768 

treatment of, 768 
Punch, cutaneous, 92 
Purpura, 405 

etiology of, 409 
pathology of, 409 
prognosis of, 410 
symptoms of, 405 
treatment of, 410 
hemorrhagica, 407 
pulicosa, 408 
rheumatica, 406 
scorbutica, 407 
simplex, 405 
urticans, 406 
urticata, 170 
Pustulae, 54 
Pustule maligne, 215 
Pustules, 54 

etc , from wounds of insects and rep¬ 
tiles, 219 

from cadaveric infection, 219 


R AY fungus, 747, 748 

Raynaud’s disease, 197, 199 
Recurrent fibroid of skin, 690 
Relaxed skin, 532 
Rete Malpighianum, 25 
Malpighii, 25 
mucosum, 25 
Reticular layer, 22 
Resorcin, 78, 88 
Rhagades, 57 
Rhinophyma, 383 
Rhinoscleroma, 562 
diagnosis of, 563 
etiology of, 563 
pathology of, 563 
prognosis of, 564 
symptoms of, 562 
treatment of, 564 
Rhynchotta, 776 
Rhynocoprion penetrans, 768 
Ringdhaaren , 515 
Ringworm, 719 
boatman’s, 744 
disseminated, 731 
giant, 744 
of scalp, 729 
yaws, 486 

Risipola Lombarda, 206 
Rochardi, unguentum, 380 
Rodent ulcer, 670 
Root of hair, 38 

sheaths of hair, 37 
inner, 38 
outer, 37 
Rosacea, 382, 482 

diagnosis of, 484 
etiology of, 483 
pathology of, 484 
prognosis of, 484 
symptoms of, 482 
treatment of, 484 
erythematosa, 483 
hypertrophica, 483 
Roseola, 161 

infantilis, 161 
scarlatiniformo, 162 
syphilitic, 608 
variolous, 142 
Rose-rash, 155 
! Rotheln , 136 

symptoms of, 136 
treatment of, 137 
Rothe schwindflechte, 283 
Rothkleie, 276 
Rothlauf, 199 
Rougeole , 132 
Rouget, 772 
Rubella, 136 
j Rubeola, 132, 136 
-! Rumex ointment, 379 
Rupia escharotica, 198 


QALVE-MUSLINS, 85 
U -pencils, 86 
Sand flea, 768 


Q UININ, 77 

Quinquaud’s disease, 509 








804 


INDEX . 


Sarcoma, alveolar, 691 

generalized primary non-melanotic, 
689 

idiopathic multiple, pigment, 689 
large round-celled, 691 
primary melanotic, 687 
non-melanotic, 688 
small round-celled, 691 
Sarcomatosis generalis, 692 
Sarcome angioplastique reticule, 556 
Sarcopsylla Westwood, 768 
Sarcoptes scabiei, 762 
Sartian disease, 669 
Satyriasis, 656 
Savill’s disease, 281 
Scabies, 757 

diagnosis of, 764 
etiology of, 762 
pathology of, 762 
prognosis of, 767 
symptoms of, 757 
treatment of, 765 
Norvegica, 762 
Scales, 55 
Scaly patches, 627 
Scarf-skin, 24 
Scar, hypertrophic, 526 
-keloid, 526 

leaving sycosiform dermatosis, 225 
Scarifying spud, 91 
Scarlatina, 137 

diagnosis of, 141 
etiology of, 140 
pathology of, 140 
prognosis of, 141 
symptoms of, 137 
treatment of, 141 
malignant, anginose, 139 
Scarlatiniform typhus, 139 
Scarlatinoide , 162 
Scarlatinoid erythema, 162 
Scarlet fever, 137 
rash, 137, 162 
Scars. 58 
Scharlach, 137 
Scheerende flechte , 729 
Schmeerjluss , 109 
Schleimhautpapeln, 626 
Schuppenflechte, 254 
Schwammformige, 485 
Scirrhous cancer, 684 
Sclerema adultorum, 468 
neonatorum, 467 
etiology of, 467 

Sclerema neonatorum, pathology of, 467 
prognosis of, 467 
symptoms of, 467 
treatment of, 468 
Sclereme des nouveau-nes, 467 
Scleriasis, 468 
Sclerodactylie, 472 
Scleroderma, 468 
diagnosis of, 473 
etiology of, 472 
pathology of, 472 
prognosis of, 474 


Scleroderma, symptoms of, 468 
treatment of, 474 
circumscribed, 469 
diffuse symmetrical, 468 
neonatorum, 467 
Sderodermie , 468 
Scrofulide erythemateuse , 590 
Scrofuloderma, 574 
pustular, 577 
Scrofuloma, 575 
“ Scrofulous ringworm,” 590 
Scurvy, 407 
Sebaceous cyst, 129 

cystic disease, rare consequences of, 
131 

flux, 109 
glands, 40 

diseases of, 109 
Seborrhagia, 109 
Seborrhea, 109 

diagnosis of, 114 
etiology of, 113 
pathology of, 114 
prognosis of, 120 
symptoms of, 109 
treatment of, 116 
congestiva, 590 
oleosa, 110 
sicca, 111 

squamosa neonatorum, 113 
Seborrhee, 109 
depilante, 225 
Senile alopecia, 497 
Septum lucidum, 27 
Shaft of hair, 38 
Shingles, 242 
j Simulia, 786 
| Skin, anatomy of, 17 
physiology of, 17 
-worms,” 124 

I Small acuminate papular syphiloderm, 612 
pustular syphiloderm, 619 
flat pustular syphiloderm, 620 
Smallpox, 142 
Smoker’s patches, 257, 547 
J “Snuffles” in syphilitic infants, 630 
[ Soaps, 81 

medicated, 81 
j Scarlatinoide, 162 
i Soaps, over-fatty, 81 
superfatted, 81 
Soft chancre, 651 
Sommer sp rosse, 411 
Spas, 79 
Spedalskhed, 656 
Sphaceloderma, 197 
“Spider cancer,” 551 
Spitzblattern, 150 
Spizen warzen , 439 
Splenic apoplexy, 215 
fever, 215 

carbuncle, 215 

Spontaneous growth, eyelids, 198 
gangrene of skin, 197 
Sporozoa, 786 
Spots, 51 






INDEX. 


805 


Spotted sickness, 756 
Spud, scarifying, 91 
Squamae, 55 
Stains, 51 

St. Anthony’s fire, 199 
Startin’s mixture, 116, 376 
Steatoma, 129 

diagnosis of, 130 
pathology of, 130 
prognosis of, 130 
symptoms of, 129 
treatment of, 130 
Steatorrhoea, 109 
Steatozoon, 767 
Stigmata, bleeding, 708 
Stili dilubiles, 86 
unguentes, 86 
Stinkender Schweiss, 105 
Stinking sweat, 105 
Stomoxis calcitrans, 775 
Stratum corneum, 27 
granulosum, 26 
lucidum, 27 
mucosum, 25 
“Strawberry marks,” 552 
Strophulus albidus, 127 
Subcutaneous injection of mercury, 645 
Sudamen, 100 
Sudatoria, 97 
Sudoriparous glands, 42 
Suette miliaire , 102 
Sulphur, 77, 89 
Summer prurigo, 402 
Superfatted soaps, 81 
Suppurative tubercular lymphangiectasis, 
575 

Surgical appliances, 90 
Swamp itch, 704 
Sweat, 45 

bloody, 108 
fetid, 105 
-glands, 42 

disorders of, 97 
-pore, 43 
stinking, 105 
Sweating, greenish, 107 
sickness. 102 
Swine-pox,. 146 
Sycosis bacillogenous, 223 
coccogenous, 223 

diagnosis of, 227 
etiology of, 226 
pathology of, 226 
prognosis of, 229 
symptoms of, 224 
treatment of, 227 
hyphogenous, 223 
lupoid, 225 
parasitica, 737 
vulgaris, 223 

Symmetrical gangrene of extremities, iy< 
etiology of, 199 
pathology of, 199 
prognosis of, 199 
treatment of, 199 

keratodermia of the extremities, 424 


Symptomatology, 50 
Symptoms, objective, 50 
subjective, 50 
Synanthemata, 59 
Synovial lesions of the skin, 444 
Syphilides, 604 

Syphilis of the mucous surfaces, 626 
tonic treatment of, 641 
Syphilitic onychia, 456 
roseola, 608 
Syphiloderma, 599 

diagnosis of, 636 
etiology of, 633 
pathology of, 634 
prognosis of, 651 
symptoms of, 600 
treatment of, 637 
bullosum, 621 

frambesioid condylomatous, 615 
gummatosum, 623 
Syphiloderma, infantile, 629 
acquisitum, 629 
hereditarium, 629 
maculosum, 608 

due to pigment-anomaly, 611 
papular, large acuminate, 613 
flat, 614 

small acuminate, 612 
flat, 613 
papulosum 611 
pustulosum, 618 

large acuminate, 619 
flat, 620 

small acuminate, 619 
flat, 620 

tuberculosum, 621 

serpiginosum, 622 
vesiculosum, 617 
| Syphilodermata, 604 

general characteristics, 604 
palmar and plantar, 616 
Syringo-cystndcnome, 545 
i Syringomyelia, 475 

rpACHE CERE BALE, 196 
1 Tache pigmentaire , 445 
Tactile corpuscles, 32 
| Tan, 157 
! Tar, 77, 87 
Tattooing, 415^ 

Teigne faveuse, 712 
tondante , 729 
I Telangiectasis, 551 
Tetia, 485 
j Texas fever, 215 
mange. 704 
The itch, 757 
Therapeutics, general, 7 3 
j Thyroid extract, 78 
| Tick, cattle, 775 
! Tinea barbae, 737 
circinata, 722 

diagnosis of, 726 
etiology of. 724 
pathology of, 724 





INDEX. 


806 


Tinea circinata, prognosis of, 729 
symptoms of, 722 
treatment of, 727 
decalvans, 501 
favosa, 712 

diagnosis of, 716 
etiology of, 714 
pathology of, 715 
prognosis of, 719 
symptoms of, 712 
treatment of, 717 
imbricata, 743 

diagnosis of, 744 
etiology of, 744 
pathology of, 744 
prognosis of, 744 
symptoms of, 743 
treatment of, 744 
kerion, 735 

symptoms of, 736 
treatment of, 736 
nodosa, 517 
sycosis, 737 

diagnosis of, 740 
etiology of, 738 
pathology of, 739 
prognosis of, 742 
symptoms of. 737 
treatment of, 741 
tondens, 729 
tonsurans, 729 

diagnosis of, 733 
etiology of, 732 
pathology of, 732 
prognosis of, 735 
symptoms of, 730 
treatment of, 734 
bald, 731 

trichophytina, 719 
cruris, 723 
unguium, 724 
versicolor, 750 

diagnosis of, 752 
etiology of, 751 
pathology of, 751 
prognosis of, 753 
symptoms of, 750 
treatment of, 753 
Toboe, 485 

Tokelau ringworm, 743 
Tonga, 485 
Tono, 485 

Torula pyogenica, 210 
Traumaticin, 87 
Treatment, internal, 74 
external, 79 
Trichauxis, 458 
Trichomycosis nodosa, 516 
Trichonosis cana, 493 
Trichopkytie sycosique , 737 
Trichophyton, 738 
Trichoptilosis, 514 
Trichorrexis nodosa, 514 
treatment of, 514 
Trombidse, 772 
True skin, 21 


Tubercle, anatomical, 570 
dissection, 570 
post-mortem, 570 
Tubercles, 53 
Tubercula, 53 

Tubercular disease of the foot, 744 
epithelioma, 671 
Tuberculoses, acne group, 577 
Tuberculosis cutis, 564 

etiology of, 579 
pathology of, 581 
prognosis of, 590 
symptoms of, 565 
treatment of, 586 
orificialis, 573 
serpiginosa ulcerativa, 572 
verrucosa, 570, 571 
fungosa cutis, 572 
papillomatosa cutis, 572 
suppurativa et bullosa acuta, 577 
Tuberculous dactylitis, 575 
eczema, 300, 578 
Tuberose carcinoma, 686 
Tumor cavernosum, 553 
Tumores, 54 
Tumors, 54 
Turpentine, 78 
Tylosis, 432 

Typhus, scarlatiniform, 139 


riLCERA, 58 
U Ulcer, Aden, 221 
cancroid, 670 
Jacob’s, 670 
Malabar, 221 
rodent, 670 
that clings, 487 
Ulcus, 59 

exedens, 670 
grave, 744 

Ulerythema acneiforme, 373, 577 
aphryogenes, 512 
centrifugum, 590 
sycosiforme, 225, 509 
Unguentum diachyli albi, of Hebra, 99 
Rochardi, 380 
Universal eczema, 358 
Uridrose, 108 
Uridrosis, 108 
Urtica dioica, 173 
urens, 173 
Urticse, 52 
Urticaria, 169 

diagnosis of, 175 
etiology of, 173 
pathology of, 174 
prognosis of, 179 
symptoms of, 169 
treatment of, 176 
ab ingestis, 173 
annularis, 170 
bullosa, 170 
evanida, 171 
figurata, 170 
hemorrhagica, 170 









INDEX. 


807 


Urticaria perstans, 171 
papulosa, 170 
pigmentosa, 171 

diagnosis of, 172 
etiology of, 172 
pathology of, 172 
symptoms of, 171 
treatment of, 172 
tuberosa, 170 
vesiculosa, 170 


VACCINATION, 151 
V Vaccine, 151 
Vaccinia, 151 
Vagabond’s disease, 784 
Varicella, 150 

diagnosis of, 150 
symptoms of, 150 
gangrenosa, 198 
Variola, 142 

diagnosis of, 148 
etiology of, 147 
prognosis of, 148 
symptoms of, 142 
treatment of, 148 
confluent, 146 
hemorrhagic, 146 
Variolette, 150 
Varioliform purpura, 146 
Varioloid, 145 
Variolous erythema, 142 
roseola, 142 

Varix lymphaticus, 479 
Varus, 369 
Vascular papillae, 24 
Vaselin, 81 

Vaso-motor and trophic neuroses, 707 
Vegetating mucous patch, 615 
Veins of the skin, 27 
Vergetures, 520 
Verruca, 438 

diagnosis of, 441 
etiology of, 441 
pathology of, 441 
prognosis of, 443 
symptoms of, 438 
treatment of, 442 
acquisita, 439 
acuminata, 439 
congenita, 439 
filiformis, 440 
glabra, 440 
necrogenica, 219, 570 
plana, 440 
senilis, 440 
vulgaris, 440 
Verrue, 438 

Verruga Peruana, 488 
Vesicles, 54 
Vesiculse, 54 
VespkUe, 786 
Vessels of skin, blood, 27 
lymphatic, 28 


1 V ibices, 405 
Vitiligo, 490 

diagnosis of, 493 
etiology of, 492 
pathology of, 492 
pi^ognosis of, 493 
symptoms of. 490 
treatment of, 493 
Vitiligoidea, 536 
Vleminckx’s solution, 380 


W AGNER, corpuscles of, 32 
Warts, 438 
moist, 439 
venereal, 439 

Warze, 438 
Wasps, 786 
Water, 80 
Wen, 129 
Wheals, 52 
giant, 53 

“White spots” on nails, 518 
Whitlow, 455 
Wilkinson’s salve, 268 
Winter prurigo, 704 
Wood-tick, 775 
Wool-fat, 86 

Wounds by reptiles and insects, 219 


X ANTHELASMA, 536 
Xanthelasmoidea, 171 
Xanthoma, 536 

diagnosis of, 540 
etiology of, 539 
pathology of, 539 
prognosis of, 541 
symptoms of, 537 
treatment of, 540 
diabeticorum, 541 
diagnosis of, 541 
etiology of, 541 
pathology of, 541 
prognosis of, 542 
symptoms of, 541 
treatment of, 542 
multiplex, 537 
papulatum, 537 
planum, 537 
tuberculosum, 537 
tuberosum, 537 
| Xeroderma, 447, 449 

pigmentosum, 447, 560 
diagnosis of, 561 
etiology of, 561 
pathology of, 561 
prognosis of, 562 
symptoms of, 560 
treatment of, 562 
I Xerosis, 447 

prognosis of, 448 
symptoms of, 448 
treatment of, 448 







808 


INDEX. 


JAWS, 485 
L caeca, 485 


70NA, 242 
Li Zoster, 242 

abdominal is, 245 
brachialis, 244 


Zoster, capillitii, 244 
collaris, 244 
facialis, 244 
femoralis, 245 
frontalis, 244 
nuchse, 244 
ophthalmicus, 244 
pectoral is, 245 



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WOHLER’S OUTLINES OF ORGANIC CHEMISTRY Translated from the 
eighth German edition, bv Ira Remsen, M.D. In one 12mo. volume of 550 pages. 
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YEAR BOOK OF TREATMENT FOR 1897. A Critical Review for Practitioners of 
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American Journal of the Medical Sciences, 75 cents. See page 1. 

YEAR-BOOKS OF TREATMENT for 1891, 1892, 1893, and-1896, similar to above. 
Each, cloth, $1.50. 

YEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. New (2d) edition. 
In one 12mo. volume of 592 pages, with 4 engravings. Cloth, $2 50. Just ready. See 
Series of Clinical Manuals , page 13. 

- A MANUAL OF MEDICAL TREATMENT, OR CLINICAL THERA¬ 
PEUTICS. Two volumes containing 1275 pages. Cloth, $5.50. 

YOUNG (JAMES K.). ORTHOPEDIC SURGERY. In one 8vo. volume of 475 
pages, with l' 86 illustrations. Cloth, $4; leather, $5. 


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